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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Use the Insurance Form to gather all of the necessary pieces if information to contact, obtain pre-authorization, and bill patient insurance plans. Customization and required fields makes records complete the first time.
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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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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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No Surprises Act Template

Send your patients your practices No Surprises Act notice, quickly and easily online.
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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 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.
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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Give patients the freedom to complete the adult ADHD self-report checklist at the most comfortable an convenient time, with a phone, tablet, or computer. Information is submitted securely and is ready for your review before the appointment.

Streamline patient forms and engagement

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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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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Kiosk Form Page

Configure a HIPAA compliant form kiosk page to display new patient registration forms, consent forms, and more.

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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.

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Save and Continue Later

Allow patients to save their progress on larger forms and packets. Patients will be able to resume where they left off and finish completing your forms at a later time.

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