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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Cancellation Policy

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Patient Satisfaction Survey

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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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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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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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.
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.

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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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User Management

Invite your team to your account and grant permissions to the exact features each user needs. Lock down assistant user accounts and give them read-only access, or give them full administrative controls.

Conditional Logic

Conditional Logic Forms

Only show information that is relevant to the patient with conditional logic forms. Make it simple for your patients to complete your forms and improve the accuracy of the data you receive with conditional logic.

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