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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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.

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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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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.
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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.
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Collect valuable information concerning your patient’s grief experience and daily life. Review this information prior to the appointment to guide the conversation.

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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.

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Setup HIPAA compliant online forms. Streamline your process of collecting information from patients.
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Sync Submissions to Google Drive

When you receive a patient form submission, automatically send the submission directly to your Google Drive folder.

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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.

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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.

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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