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.
Patient Satisfcation Survey Template

Patient Satisfaction Survey

Follow up with your patients by sending this patient satisfaction survey. Your patients are your customers and patient satisfaction is critical to ensuring the success of your practice.
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.
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.

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.
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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.
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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.
Medical History Form Template

Medical History 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.
Medical Intake Form Template

Medical Intake Form

Easily have patients complete your medical intake forms online. Completed medical intake forms are submitted securely to your account, before the patient's appointment.

Streamline patient forms and engagement

Collect forms. Engage patients. Automate follow-up.

Discover More Form Features

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

Conditional Logic Forms

Only show information that is relevant to the patient with conditional logic forms. Make it simple for your patients to complete your forms and improve the accuracy of the data you receive with conditional logic.

Form Analytics

Form Analytics

Analyze data, improve patient responses, learn from patient behavior and raise your conversion rate. FormDr is the only tool you require to understand the needs of your patients.

HIPAA Compliant Online Intake Forms

HIPAA Compliant Online Intake Forms

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.

Encrypted HIPAA Compliant Forms

Encrypted HIPAA Compliant Forms

Your forms are protected with a 128-bit secure socket layer which encrypts your patient’s data. Securely collect patient forms online with HIPAA compliant online forms.

Book a Free Demo

Schedule a demo to see how FormDoctor can streamline patient forms and automate engagement.

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