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.

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.
Medical Consent Form Template

Medical Consent Form

Easily have patients complete your medical consent form with their phone, tablet, or computer. Make it easy for patients to complete your consent forms online.
Medical Consent Form for Child Template

Medical Consent Form for Child

Have parents and guardians electronically sign medical consent forms for children. Parents and guardians can easily sign HIPAA compliant online forms with their phone, tablet, or computer.
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.
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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.
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.
Telehealth Consent Form Template

Telehealth Consent Form

Collect telehealth consent forms online. Send your clients telehealth forms, give clients the ability to sign HIPAA compliant online forms with any device, anywhere.

Advance Beneficiary Notice of Noncoverage

Easily keep your patients informed, while fulfilling Medicare requirements by sending this form when you suspect an item may not be covered under Medicare. Keeping your patients informed empowers them with the information to make the best health and financial decisions.

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.
Prefilled HIPAA Compliant Forms

Prefilled Forms

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.

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.

HIPAA Compliant File Upload

File Attachment Upload

With file upload fields, your patients can upload their prescriptions, x-rays, medical records, insurance card photos and more with their form submission.

Text Message Form Invites

Text Message Invitations

Send a text message invitation to your patients to complete your forms. Give patients the freedom to sign and complete forms with any device, anywhere.

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