healthcare: verify wet-signature requirements across all services
Source-grounded check of which services need an ORIGINAL ink signature (plotter target) vs e-sign/typed. Verified firsthand against the official forms: - Confirmed wet-ink: the 5 CMS Medicare/NPI paper filings only (855I/B/O + 10114), which are exactly the no-login Standard-path filings the plotter serves. - CLIA CMS-116 does NOT require original ink — the form explicitly permits 'SIGN IN INK OR USE A SECURE ELECTRONIC SIGNATURE', so our digital stamp suffices; plotter optional for CLIA. - DEA registration/renewal is online-only (Form 224 unavailable in PDF), e-certified, no wet ink. - State CSR / state Medicaid are the only open items: paper in many states but original-ink-vs-e-sign is state-specific; verify per state. - All FCC/telecom/DOT/BOC-3/CRTC/PUC filings are electronic (e-sign fine). Added the verified matrix to state-healthcare-compliance-opportunities.md, saved docs/CMS-116 Form.pdf, and the plotter plan.
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# Plotter Plan — ink-signature station for no-login CMS filings
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Goal: turn the (already-built) ink-signature pipeline into a reliable physical
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station that draws an **original wet-ink signature** on each printed CMS form so
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the Standard (no-login) filing path can be mailed and accepted. The CR-10 V2 is
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the motion system; this plan covers the retrofit, calibration, the
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software/hardware integration that remains, validation, and the operational
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runbook.
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Status legend: ✅ done · 🔲 to do · ⏳ blocked on hardware
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---
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## 0. What already exists (software, hardware-independent)
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- ✅ `signature_vector` capture end-to-end (migration 090, signing page, API).
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- ✅ `ink_signature_plotter.py` — fit-to-box, PDF-pt → bed-mm, G-code (Z pen or
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M280 servo/BLTouch), SVG preview, `render_signature_on_pdf` digital twin,
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gated serial sender.
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- ✅ `ink_signature_cli.py` — load record → gcode + preview, `--test-box`,
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`--plot`.
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- ✅ `test_ink_signature.py` 30/30; signature anchor verified inside the
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CMS-10114 Section 4A cell.
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- ✅ `docs/ink-signature-plotter.md` — retrofit + interpretive-risk writeup.
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The remaining work is hardware + a few integration/safety pieces.
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---
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## 1. Hardware retrofit (CR-10 V2)
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1. 🔲 **Pen holder.** Print a spring-loaded CR-10/Ender X-carriage pen holder
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(Printables/Thingiverse). Spring = even contact pressure. Print it before
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converting (you still have the hotend).
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- BOM: printed bracket, 1 compression spring (~8–12mm), 2–3× M3 screws, a
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smooth **gel/rollerball** pen (wet ink, hand-written look).
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2. 🔲 **Mount + cable management.** Attach beside the hotend; make sure the pen
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tip is the lowest point and the bed can still home.
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3. 🔲 **Pen-up/down method — pick one:**
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- *Z mode (default, simplest):* pen fixed; G-code lifts/drops Z. Spring
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forgives over-press. No firmware change.
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- *Servo/BLTouch mode (optional):* actuate pen with a servo or repurpose the
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BLTouch; `--servo-pen` emits `M280`. Faster, no Z lash, more build effort.
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- **Decision:** start Z mode; revisit servo only if Z lift is too slow.
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4. 🔲 **Paper jig.** Tape an L-shaped corner stop to the bed (front-left) so a
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US-Letter sheet always sits at the same `(jig_x_mm, jig_y_mm)`. This is the
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single most important accuracy factor.
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5. 🔲 **Pen-touch Z reference.** Either set `pen_down_mm` by hand, or use the
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BLTouch to probe a fixed point on the jig for a repeatable touch height.
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Reversibility: nothing here is permanent; swap the hotend back to print anytime.
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---
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## 2. First-light calibration (uses --test-box)
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1. 🔲 Connect: CR-10 enumerates as CH340 `/dev/ttyUSB0` @ 115200. Confirm with
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`ls -l /dev/ttyUSB*` and a manual `G28` via pronterface/printrun.
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2. 🔲 Dry-run inspect: `ink_signature_cli.py --order <X> --doc cms10114
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--test-box` → review the `_testbox.gcode` + `_preview.svg`.
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3. 🔲 Plot the box on a **blank** sheet in the jig:
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`--test-box --plot --home --port /dev/ttyUSB0`.
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4. 🔲 Print a real (unsigned) CMS-10114 cert page, lay it in the jig, plot the
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test box again, and confirm the rectangle frames the Section 4A signing cell.
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5. 🔲 Tune `--jig-x/--jig-y` (position) and `--pen-down` (ink without digging in)
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until the box lands on the line. **Record the final values** as the station
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defaults.
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6. 🔲 Bake the calibrated defaults into `PlotterConfig` (or a small
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`plotter_config.json` the CLI/worker reads), so operators don't pass flags.
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Acceptance: the plotted rectangle sits within ~1mm of the cell, repeatably,
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across 3 reloads of the sheet.
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---
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## 3. Software/integration still to build
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1. 🔲 **Persisted station config.** `scripts/workers/services/plotter_config.json`
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(jig offset, pen heights, feeds, port) loaded by `PlotterConfig.from_file()`.
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Keeps calibration out of code + flags.
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2. 🔲 **Anchor scaling parity test.** A test that plots/previews against a page
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whose `page_w/page_h` differ from the authored size, asserting the strokes
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still land in the cell (the stamper already scales; add the matching ink
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test).
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3. 🔲 **Signature-quality guard.** Reject/flag vectors that are too few points,
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near-empty bbox, or a single dot (someone tapped instead of signing) before
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they reach the pen. Add to `ink_signature_plotter` + a unit test.
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4. 🔲 **855 anchors for ink.** `cms855_pdf_filler` only has the 855I signature
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rect today; add 855B/O/A signature rects so org filings can also be plotted
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(currently human-placed). Mirror the CMS-10114 anchor approach.
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5. 🔲 **Batch integration.** Teach `daily_paper_batch.py` to, for each signed
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filing in a batch: (a) print the filled form, (b) call the plotter to ink the
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signature, (c) include it in the per-agency envelope. Sequencing + a
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per-sheet "plotted ✓" status column so a crash doesn't double-sign or skip.
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6. 🔲 **Plot audit trail.** Store the emitted G-code hash + a post-plot photo (if
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a camera is added) on the esign/batch record for traceability.
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7. 🔲 **Operator safety.** `--plot` already gated; add a hard env guard
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(`INK_PLOTTER_ENABLED=1`) so a stray `--plot` on a dev box can't move a
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machine, and a `--confirm` prompt for live runs.
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---
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## 4. Validation (build verifiable criteria)
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- 🔲 **Geometry (done, extend):** keep `test_ink_signature.py` green; add the
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page-scale parity + quality-guard tests above.
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- 🔲 **Physical accuracy:** a calibration card — plot a 10mm grid + the test box,
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measure with calipers, assert ≤1mm error. Document the measured numbers.
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- 🔲 **Legibility:** plot 5 real captured signatures, scan, eyeball that each is
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recognizably the signer's mark (not mangled by resampling). Tune
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`min_segment_mm` / feeds if jagged.
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- 🔲 **Ink originality sanity:** confirm under magnification the line is
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continuous wet ink (not dotty), since "deemed not original" is the failure mode
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we're guarding against.
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- 🔲 **End-to-end dry run:** one fake order → form printed → signature plotted →
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batched → addressed envelope, with nothing actually mailed.
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---
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## 5. Go-live policy (interpretive risk)
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CMS does not explicitly bless/ban autopen for the 855/10114. Therefore:
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1. 🔲 **Two paths, choose per filing:**
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- *Plotter (fast):* default for low-stakes changes (e.g. address/contact
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NPPES updates) where a re-file is cheap.
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- *True wet-signature mail-out (safe):* a printed packet to the provider
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(cover sheet with a signing arrow + return envelope) for high-stakes
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filings (enrollment, reactivation) until acceptance is proven.
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2. 🔲 **Pilot:** run a handful of real plotter-signed filings, track acceptance
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vs rejection at the MAC/Enumerator. If clean, widen the plotter default.
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3. 🔲 **Kill switch:** if any rejection cites the signature, fall back to wet-sig
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mail-out for that service and log it.
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Note: never expose any of this (plotter, paper, ink, MAC, Enumerator) in
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client-facing copy — same rule as the rest of the no-login model.
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---
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## 6. Operational runbook (once calibrated)
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```
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# Daily, per signed Standard filing (or via daily_paper_batch once wired):
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1. Print the filled, unsigned form (form printer, plain paper).
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2. Lay the cert page in the jig on the CR-10.
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3. Plot the signature:
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INK_PLOTTER_ENABLED=1 python scripts/workers/ink_signature_cli.py \
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--order CO-XXXX --doc cms10114 --plot --home --confirm
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4. Verify the ink landed on the line; reassemble the form pages.
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5. Hand to the daily batch -> per-agency Priority Mail envelope.
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```
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---
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## 7. Sequence (what to do, in order)
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1. Print + mount the spring pen holder; tape the jig. (§1)
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2. Calibrate with `--test-box`; record jig/pen values. (§2)
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3. Add persisted `plotter_config.json` + load it. (§3.1)
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4. Add quality guard + page-scale parity tests. (§3.2–3.3)
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5. Physical accuracy + legibility validation. (§4)
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6. Wire into `daily_paper_batch` with per-sheet plotted status. (§3.5)
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7. Add env/confirm safety guards. (§3.7)
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8. Pilot live filings under the go-live policy; widen or fall back. (§5)
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9. (Later) 855B/O/A anchors so org filings can be plotted too. (§3.4)
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---
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## Dependencies / risks
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- ⏳ Everything in §1–2 is blocked on the pen holder + jig (cheap, fast).
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- Risk: jig drift → signature off the line. Mitigate with a fixed, screwed-down
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jig and a per-session `--test-box` check.
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- Risk: pen dry-out / skipping → illegible mark. Mitigate with gel/rollerball +
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legibility validation + a "prime the pen" pre-stroke.
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- Risk: CMS deems plotted signature "not original." Mitigate with the two-path
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go-live policy + pilot.
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@ -119,3 +119,37 @@ sharing). Categories:
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> to the state) and state CSR are the cleanest A-category additions and slot
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> straight into the existing daily batched-mail flow grouped by state agency —
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> the same machinery built for CMS-855 → MAC.
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## Wet-signature (original ink) requirement — verified check
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Determines which services need the pen-plotter ink-signature pipeline (an
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ORIGINAL ink signature on a mailed form) vs an e-signature / typed attestation.
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Source = the official form's signature/submission language, checked firsthand.
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| Service | Channel | Signature requirement | Wet ink needed? | Source (verbatim) |
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|---|---|---|---|---|
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| NPPES update | mail | original, in ink | **YES** | CMS-10114: *"All signatures must be original and signed in ink... Stamped, faxed or copied signatures will not be accepted."* |
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| NPI reactivation | mail | original signatures | **YES** | CMS-855I: *"Send this completed application with original signatures..."* |
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| Medicare revalidation | mail | original signatures | **YES** | CMS-855I/B (same) |
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| Medicare enrollment | mail | original signatures | **YES** | CMS-855I/B/O (same) |
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| Provider compliance bundle | mail | inherits 855/10114 | **YES** (its filing pieces) | spawns the above |
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| **CLIA certificate (CMS-116)** | mail → State Agency | **ink OR secure e-signature** | **NO** | CMS-116: *"SIGNATURE OF OWNER/DIRECTOR OF LABORATORY (SIGN IN INK OR USE A SECURE ELECTRONIC SIGNATURE)."* So a stamped/secure e-sig is acceptable; plotter optional, not required. |
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| DEA registration / renewal | online | electronic certification | **NO** | DEA online webforms (Form 224 "unavailable in PDF" — new individual reg is online-only); registrant e-certifies. |
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| State CSR | varies by state | state-specific | **MAYBE (per state)** | Most states: paper application the client signs; a minority are portal-only. Original-ink vs e-sig is state-by-state — verify per state before plotting. |
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| State Medicaid enroll/reval | varies by state | state-specific | **MAYBE (per state)** | Where paper, the state packet's signature rule governs; verify per state. |
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| MCS-150 / DOT, BOC-3, all FCC/telecom, CRTC, PUC, PDMP(portal), license renewals | online/portal/fax | e-sign or typed | **NO** | electronic submission; our e-sign + digital stamp flow suffices. |
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### Conclusions
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- **Confirmed wet-ink (plotter target):** the five CMS Medicare/NPI paper filings
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only. These are exactly the no-login Standard-path filings the plotter serves.
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- **CLIA does NOT require original ink** — the CMS-116 explicitly permits a secure
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electronic signature, so our existing digital-stamp e-sign is sufficient; the
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plotter is optional for CLIA, not mandatory.
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- **DEA = electronic**, no wet ink.
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- **State CSR / state Medicaid are the only open items**: they are paper in many
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states but the original-ink-vs-e-sign rule is state-specific. Verify each
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target state's packet before relying on the plotter (or just plot to be safe,
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since an ink signature satisfies a state that accepts either).
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- **Gap for plotting org filings:** `cms855_pdf_filler` currently maps the 855I
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signature anchor only; add 855B/O/A anchors (plotter-plan §3.4) before plotting
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organization enrollment/revalidation.
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