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.
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.
Telehealth Consent Form Template

Telehealth Consent Form

Collect telehealth consent forms online. Send your clients telehealth forms, give clients the ability to sign HIPAA compliant online forms with any device, anywhere.
hipaa-authorization-form

HIPAA Authorization Form

Stay in compliance and make sure you have the correct HIPAA information on file for each patient. The electronic HIPAA Authorization form is customizable and an easy way for your patients to keep their information updated.
no-surprises-act-form-template-icon

No Surprises Act Template

Send your patients your practices No Surprises Act notice, quickly and easily online.

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.
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.
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.
adhd-self-report-form-template

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.

Build a HIPAA compliant form for free

Start saving time and money with FormDr

Discover More Form Features

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

Save and Continue Later

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.

HIPAA Compliant Online Intake Form Packets

Intake Form Packets

Combine multiple pages into an online form packet. Have your patients fill out their medical history, consent to treat, and demographics all in one new patient intake form packet.

Form Analytics

Form Analytics

Analyze data, improve patient responses, learn from patient behavior and raise your conversion rate. FormDr is the only tool you require to understand the needs of your patients.