No Surprises Act Form Template

Easily send and receive your practices No Surprises Act form to patients, online. Provide digital notice that includes language regarding patient protections against surprise billing.
No Surprises Act

What is the No Surprises Act Form Template?

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.

It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges. Read more about the No Surprises Act.

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Send your patients your practices No Surprises Act notice, quickly and easily online.
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Have your patient take a picture of their insurance and ID cards. New patients will automatically upload a photo of their card information, so you can verify it before the appointment.

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Schedule automatic reminders to your patients to complete your forms before their appointment. Get more completed forms online before the scheduled appointment.

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Invite your team to your account and grant permissions to the exact features each user needs. Lock down assistant user accounts and give them read-only access, or give them full administrative controls.

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When you receive a patient form submission, automatically send the submission directly to your Google Drive folder.

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FormDoctor gives your practice one HIPAA-compliant platform to collect forms, communicate with patients, and automate follow-up. We help practices who:

  • Are still using paper forms, PDFs, or Word documents
  • Spend too much time printing, scanning, emailing, and calling patients
  • Need an easier way to send reminders and automate follow-ups
  • Want to streamline forms, communication, and paper workflows