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.
grief-evaluation-form-template

Grief Evaluation for Children & Teenagers (17 and Under)

Collect valuable information concerning your patient’s grief experience and daily life. Review this information prior to the appointment to guide the conversation.
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.
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.
no-surprises-act-form-template-icon

No Surprises Act Template

Send your patients your practices No Surprises Act notice, quickly and easily online.

Notice of Privacy Practices

Easily comply with the HIPAA Privacy Rule by providing your patients with an electronic privacy notice to read and complete before the initial visit. The notice can be read when convenient, signed and then returned for an informed, efficient clinic visit.

Edinburgh Postnatal Depression Scale Form

Use this standardized screening checklist to identify postpartum depression symptoms and determine the severity of illness.
phq9-teen-form-template

PHQ-9 Modified for Teens

Give your teen 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.
insurance form template icon

Insurance Form

Use the Insurance Form to gather all of the necessary pieces if information to contact, obtain pre-authorization, and bill patient insurance plans. Customization and required fields makes records complete the first time.

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.
Appointment Reminder

Patient Appointment Reminder

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

Drawing and Diagrams

Drawing and Diagrams

Allow your patients to draw on an image or diagram in your form to mark areas of pain or parts of the body that may need treatment.

Trusted Devices Authorization

Skip two-factor authentication using Trusted Devices. Trusted Devices provides an extra layer of security for your FormDr account while saving time.

Export to PDF

Export Form Submissions to PDF

Quickly export complete patient forms to a PDF file. Save completed forms as a PDF to quickly attach patient records.

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