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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Streamline your medical forms online. Automate your paperwork. Start saving time and money.
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No Surprises Act Template

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

Notice of Privacy Practices

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Patient Intake Form

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Medical Consent Form

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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.
Appointment Reminder

Patient Appointment Reminder

Schedule automatic reminders to your patients to complete your forms before their appointment. Get more completed forms online before the scheduled appointment.

Export to Excel

Export Form Submissions to Excel

Export multiple patient forms into a Microsoft Excel compatible CSV file. Take control of your patient data with a bulk export, and import your complete patient forms into a database, excel spreadsheet, or EHR.

Custom Thank You Page

Custom Thank You Page

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.

HIPAA Compliant Form Submissions

HIPAA Compliant Form Submissions

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

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