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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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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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.
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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.
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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.
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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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Setup an AIMS Form for free. Allow your clinicians to complete an Abnormal Involuntary Movement Scale Form safely and securely, online.
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Give your 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.
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Collect telehealth consent forms online. Send your clients telehealth forms, give clients the ability to sign HIPAA compliant online forms with any device, anywhere.

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.
HIPAA Compliant Form Submissions

HIPAA Compliant Form Submissions

Patients sign and submit forms securely to your online account. Review and manage completed patient forms before the appointment.

Automated Bulk Export

SFTP Automated Bulk Export

Generate a bulk export of patient submissions that will be saved as a CSV Excel file. Select your frequency, time of day to export, and which forms you would like to export submissions from.

Encrypted PHI

Encrypted PHI ePHI

All PHI is encrypted in transit and at rest—while being submitted back to your account and at rest in our database. Protect sensitive data with fully encrypted patient submissions.

Centralized Administrative Management

Centralized Team Management

Create administrative accounts by department, location, or clinic. Filter and segment your organization by setting up additional administrative users.

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