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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Custom QR Code

Generate a unique QR code to print and/or share with patients. They can point, scan and access intake forms easily.

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Create your own custom ‘Thank You’ page to direct patients to upon completion of your forms. Forward them along to the next steps of your intake process.

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Keep a detailed record of your account and export your history as a CSV Excel file or Google Sheet. Quickly export every event from your account; or, select a date range or user’s history to export.

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

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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