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.

More Online Medical Forms

Streamline your medical forms online. Automate your paperwork. Start saving time and money.
insurance form template icon

Insurance Form

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.
Medical Intake Form Template

Medical Intake Form

Easily have patients complete your medical intake forms online. Completed medical intake forms are submitted securely to your account, before the patient's appointment.
grief-evaluation-form-template

Grief Evaluation for Children & Teenagers (17 and Under)

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

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.
Patient Satisfcation Survey Template

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.

Notice of Privacy Practices

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.
Patient Intake Form Template

Patient Intake Form

Easily have patients complete your patient intake forms online. Completed patient intake forms are submitted securely to your account, before the patient's appointment.
phq9-teen-form-template

PHQ-9 Modified for Teens

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.

Build a HIPAA compliant form for free

Start saving time and money with FormDr

Discover More Features

Setup HIPAA compliant online forms. Streamline your process of collecting information from patients.
Card Photo Uploads

Card Photo Uploads

Have your patient take a picture of their insurance and ID cards. New patients will automatically upload a photo of their card information, so you can verify it before the appointment.

square payment processing icon

Square Payment Processing

Quickly and efficiently collect patient payments using a HIPAA-compliant payment processing widget with reporting capabilities and the easy customizations you expect from FormDr.

Text Message Form Invites

Text Message Invitations

Send a text message invitation to your patients to complete your forms. Give patients the freedom to sign and complete forms with any device, anywhere.

HIPAA Compliant Tablet Forms

Forms on iPads or Tablets

Give patients the option to sign and complete forms online with an iPad or tablet. Online forms work on all tablets and iPads.

Book a Free Consultation

Schedule a consultation with us to learn more

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