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.
cancellation-policy-

Cancellation Policy

Collect signed acknowledgements of the clinic cancellation policy online before the appointment. Informed patients provide better communication, which in turn reduces your clinic no-shows and late cancellations.
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.
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.
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.
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.
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.
Medical Consent Form Template

Medical Consent Form

Easily have patients complete your medical consent form with their phone, tablet, or computer. Make it easy for patients to complete your consent forms online.

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.

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.
HIPAA Compliant Online Intake Forms

HIPAA Compliant Online Intake Forms

Emailing new patient intake forms risks the interception of PHI. FormDr is HIPAA compliant, all patient data is encrypted in transit and rest. A Business Associate Agreement is included with your account.

HIPAA Compliant Submission Audit Logs

Submission Audit Logs

Form submissions have a detailed history that can always be referenced. Audit logs cannot be changed and the history from all users is tracked.

HIPAA Compliant Forms Dedicated Server

Dedicated Servers

Host your HIPAA compliant online forms and PHI on a dedicated server with a FormDr White Label Enterprise account. Keep your patient’s data secure while collecting form submissions with any device, anywhere, at any time.

User Management

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.