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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No Surprises Act Template

Send your patients your practices No Surprises Act notice, quickly and easily online.
Medical History Form Template

Medical History 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.

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.
Medical Consent Form Template

Medical Consent Form

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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.

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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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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.

Edinburgh Postnatal Depression Scale Form

Use this standardized screening checklist to identify postpartum depression symptoms and determine the severity of illness.

Streamline patient forms and engagement

Collect forms. Engage patients. Automate follow-up.

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Sync HIPAA Compliant Form Submissions to Google Drive

Sync Submissions to Google Drive

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

Required HIPAA Compliant Form Fields

Required Form Fields

Always get the information you need with required fields. Patients can only submit when they complete all of your required fields. Never receive an incomplete medical form again.

Embed Forms on Website

Embed Forms on Website

Embed your forms directly on your website for a seamless experience for your patients. Your forms are customized with your logo, brand, and styling to match your site. Embed on Wordpress, Wix, Squarespace, and many more.

Mobile Friendly Forms

Mobile-Friendly Forms

Easily build fully-responsive medical forms online that allow your patients to sign and submit on any device, anywhere, at any 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