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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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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Have your patient enter information once and have it autocomplete throughout your medical form online. Automatically populate PHI directly into additional fields and medical consent forms.

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Send a prefilled contracts, agreements, and forms to have patients securely sign forms customized for them. Create financial contracts with pricing specific to the patient.

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Patients sign and submit forms securely to your online account. Review and manage completed patient forms before the appointment.

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SFTP Automated Bulk Export

Generate a bulk export of patient submissions that will be saved as a CSV Excel file. Select your frequency, time of day to export, and which forms you would like to export submissions from.

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