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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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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Easily have patients complete your medical intake forms online. Completed medical intake forms are submitted securely to your account, before the patient's appointment.
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Easily have patients complete your HIPAA compliant telemedicine consent form with their phone, tablet, or computer. Make it easy for patients to complete your consent forms online.
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Collect telehealth consent forms online. Send your clients telehealth forms, give clients the ability to sign HIPAA compliant online forms with any device, anywhere.
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Give your teen patients the freedom to complete the PHQ-9 from any device, anywhere. Ensure privacy and help keep teens safe by ensuring completion of this screening form before their clinic visit.
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Give your patients the freedom to complete the PHQ-9 from any device, anywhere. Ensure privacy and help keep teens safe by ensuring completion of this screening form before their clinic visit.
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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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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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Setup HIPAA compliant online forms. Streamline your process of collecting information from patients.

EHR & EMR Integration

Share patient data back and forth from FormDr to common EMR systems seamlessly with EHR Integrations.

HIPAA Compliant Online Intake Forms

HIPAA Compliant Online Intake Forms

Emailing new patient intake forms risks the interception of PHI. FormDr is HIPAA compliant, all patient data is encrypted in transit and rest. A Business Associate Agreement is included with your account.

Account Audit Logs

Account Audit Logs

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.

User Management

Interoperability

FormDr provides interoperability and customization solutions for every need, including Open API and select EMR / EHR integrations.

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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