Form HCFA-487 at a glance
What it is: Form HCFA-487 is an addendum to the plan of treatment or medical update.
Who signs: Under 9. Signature of Physician, the physician signs and enters 10. Date.
A filled-in Form HCFA-487 example: an addendum to the plan of treatment
How to fill out Form HCFA-487, box by box
Addendum to plan of treatment or medical update
On the Health Care Financing Administration form, mark ADDENDUM TO: PLAN OF TREATMENT or MEDICAL UPDATE.
Claim No., SOC Date, Certification Period and Provider No.
Enter 1. Patient's HI Claim No., 2. SOC Date, 4. Medical Record No. and 5. Provider No.
Enter 3. Certification Period From: and To:.
Patient and provider names
Enter 6. Patient's Name and 7. Provider Name, then 8. Item. No.
Signature of physician
Under 9. Signature of Physician, the physician signs and enters 10. Date.
Optional name or signature of nurse or therapist
Under 11. Optional Name/Signature of Nurse/Therapist, enter the name or signature and 12. Date.
Sources
[1] Form HCFA-487 (4-87), Addendum to Plan of Treatment / Medical Update, Health Care Financing Administration (the Official source link on this page).