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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No Surprises Act Template

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

Streamline patient forms and engagement

Collect forms. Engage patients. Automate follow-up.

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Setup HIPAA compliant online forms. Streamline your process of collecting information from patients.
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Print your patients’ submissions after the forms have been completed online. Adjust the formatting and text size to match your original paper forms.

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All PHI is encrypted in transit and at rest—while being submitted back to your account and at rest in our database. Protect sensitive data with fully encrypted patient submissions.

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Emailing new patient intake forms risks the interception of PHI. FormDr is HIPAA compliant, all patient data is encrypted in transit and rest. A Business Associate Agreement is included with your account.

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Create administrative accounts by department, location, or clinic. Filter and segment your organization by setting up additional administrative users.

Book a Free Demo

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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