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.

More Online Medical Forms

Streamline your medical forms online. Automate your paperwork. Start saving time and money.
Telemedicine Consent Form Template

Telemedicine Consent Form

Easily have patients complete your HIPAA compliant telemedicine consent form with their phone, tablet, or computer. Make it easy for patients to complete your consent forms online.
cancellation-policy-

Cancellation Policy

Collect signed acknowledgements of the clinic cancellation policy online before the appointment. Informed patients provide better communication, which in turn reduces your clinic no-shows and late cancellations.
aims-form-template-icon

AIMS (Abnormal Involuntary Movement Scale)

Setup an AIMS Form for free. Allow your clinicians to complete an Abnormal Involuntary Movement Scale Form safely and securely, online.

Advance Beneficiary Notice of Noncoverage

Easily keep your patients informed, while fulfilling Medicare requirements by sending this form when you suspect an item may not be covered under Medicare. Keeping your patients informed empowers them with the information to make the best health and financial decisions.
COVID-19 Screening Form Template

COVID-19 Screening Form

Send patients COVID-19 screening forms to fill out on their phone, tablet, or computer. Safely screen patients for COVID-19 by enabling them to fill out forms on their own device.
hipaa-authorization-form

HIPAA Authorization Form

Stay in compliance and make sure you have the correct HIPAA information on file for each patient. The electronic HIPAA Authorization form is customizable and an easy way for your patients to keep their information updated.
Medical Release Form Template

Medical Release Form

Turn your paper medical history forms into HIPAA compliant online forms. Streamline your forms by removing the paperwork. Collect a more accurate medical history from your patients.
phq9-form-template-icon

Patient Health Questionnaire (PHQ-9)

Give your patients the freedom to complete the PHQ-9 from any device, anywhere. Ensure privacy and help keep teens safe by ensuring completion of this screening form before their clinic visit.

Build a HIPAA compliant form for free

Start saving time and money with FormDr

Discover More Features

Setup HIPAA compliant online forms. Streamline your process of collecting information from patients.
Reporting

Custom Reporting

Monitor text messaging effectiveness to see patient response rates, track appointment scheduling trends to reduce no-shows, and analyze phone call data for improved communication. Gain insights into your opportunity pipeline to identify potential patients and increase conversions, while leveraging mass messaging analytics to measure outreach success.

Print HIPAA Compliant Submissions

Print HIPAA Compliant Form Submissions

Print your patients’ submissions after the forms have been completed online. Adjust the formatting and text size to match your original paper forms.

HIPAA Compliant Two-Way Texting

Improve engagement and efficiency with real-time, HIPAA-compliant messaging. FormDr’s secure messaging platform enables real-time communication between healthcare providers and patients.

Sync HIPAA Compliant Form Submissions to Google Drive

Sync Submissions to Google Drive

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

Book a Free Consultation

Schedule a consultation with us to learn more

FormDr gives your practice everything needed to easily send and receive HIPAA compliant forms online. We help practices who:

  • Are having patients fill out paper forms during the appointment
  • Are emailing patients a PDF or Word Doc to print out, fill out, scan, and send back
  • Are spending time manually printing and scanning paper forms