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Healthcare No Surprises Act Form

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HEALTHCARE NO SURPRISES ACT FORM

This form documents the patient notice and election required by the No Surprises Act and applicable implementing regulations. It provides a Good Faith Estimate of expected charges for scheduled items and services and records any voluntary consent to receive out-of-network services and potential balance billing. Completion of this form is an attestation of your understanding of the statements below and is subject to the certifications and authorizations contained herein.

Patient Information

Date of Birth:

Gender:

Insurance Information

Provider and Service Information

Scheduled Service Date:    Procedure / Service Code or Description:

Itemized Estimate (Optional)

Line Item 1

Line Item 2

Line Item 3

Patient Rights, Notices, and Elections

Notice of Patient Protections: Under the No Surprises Act, you generally have protection from surprise billing for certain emergency services and certain nonemergency services performed by out-of-network providers at in-network facilities. You have the right to receive a Good Faith Estimate of expected charges for scheduled services if you are uninsured or plan to self-pay.

Please indicate which of the following applies (select one or more as applicable):

I request a Good Faith Estimate for the scheduled items/services described above and understand this estimate is based on information available at the time of this request.

I acknowledge I have been informed of my rights under the No Surprises Act and have received a verbal or written explanation of protections against balance billing.

Voluntary Consent to Balance Billing: If you elect to receive nonemergency care from an out-of-network provider at an in-network facility, you may be billed directly by the out-of-network provider for amounts beyond what your plan pays. To consent to such billing, you must provide informed, written consent at least 72 hours prior to the scheduled service.

I voluntarily consent to receive the scheduled nonemergency services from the out-of-network provider named above and understand I may be balance billed for amounts not covered by my plan. I understand this consent is revocable and I may withdraw consent at any time prior to the service.

Privacy and HIPAA Acknowledgment

I acknowledge that I have been provided with the provider's Notice of Privacy Practices and that my health information may be used or disclosed as necessary to provide treatment, obtain payment, or for health care operations related to the services described herein.

I acknowledge receipt of the Notice of Privacy Practices and authorize uses and disclosures of my protected health information as described.

Authorizations, Certifications, and Expiration

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I understand that the Good Faith Estimate is an estimate only and actual charges may differ due to changes in service, ancillary items, or unforeseen clinical circumstances. I understand my rights to dispute a bill or seek review if I believe charges are inconsistent with this estimate or otherwise incorrect.

Patient Attestation and Signature

By signing below I attest that I have read and understand this form, that I have had the opportunity to ask questions, and that I consent to the selections indicated above where applicable. I understand that if I consent to balance billing I may revoke that consent prior to the service.

Patient Printed Name:

Signature:

Date:

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What the Healthcare No Surprises Act Form Is

The Healthcare No Surprises Act Form documents notice and cost-estimate communications required under the federal No Surprises Act and implementing CMS guidance. It records patient identity, provider and facility details, a good-faith estimate or notice of potential balance billing, and any patient acknowledgments. The form is used by clinicians, facilities, and insurers to demonstrate disclosure efforts, manage disputes, and create an auditable record for compliance and billing reconciliation.

Why this form matters for patients and providers

Completing the Healthcare No Surprises Act Form helps document disclosures, reduces the risk of surprise balance billing, and supports dispute resolution. Electronic completion is generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.

Why this form matters for patients and providers

Who typically completes or receives this form

The Healthcare No Surprises Act Form is completed and used by multiple parties across care and billing workflows.

  • Health care providers and clinic administrators who deliver or schedule services and must disclose estimated charges and network status.
  • Insurers and third-party administrators that receive the notice to process claims and manage potential disputes or notices of liability.
  • Patients or authorized representatives who review, acknowledge, or dispute estimated charges and receive formal notice of their rights.

Clear assignments and retained copies reduce later disputes and support audits by regulators or payers.

Step-by-step: completing the No Surprises Act Form

Follow this sequential checklist to prepare, verify, and submit the form accurately.

  • 01
    1. Gather records: Collect patient identification, insurance details, and scheduled service information.
  • 02
    2. Verify coverage: Confirm payer, plan type, and network status before estimating costs.
  • 03
    3. Complete form: Enter provider, facility, procedure codes, and a good-faith estimate or balance-billing notice.
  • 04
    4. Send and retain: Transmit to patient and payer; store an auditable copy for compliance.

Configuring a secure online workflow

Set up template fields, authentication, and retention rules before sending forms to patients or payers.

Field Configuration
Authentication method Email link or SMS code; choose stronger KBA for disputed cases
Field mapping Map NPI, member ID, and dates to EHR or billing system fields
Conditional fields Show cost estimate fields only when insurance is unknown or self-pay
Retention policy Automate storage duration and export of audit trails for compliance

How electronic submission and routing typically operate

Electronic workflows reduce manual handoffs but require clear routing rules and audit capture.

  • Upload document: Sender uploads the templated form in PDF or DOCX format.
  • Place fields: Insert signature, date, and conditional fields for payer information.
  • Signer receives: Patient and provider receive secure signing links via email or SMS.
  • Submit to payer: Transmit signed copy and capture a certificate of completion for records.

Selecting a compliant eSignature platform

Choose a platform that supports HIPAA-level protections, common document formats, and integrations with clinical or billing systems.

  • Supported formats: PDF, DOCX, and saved audit trail exports
  • Integrations: Connectors for EHR, billing, or cloud storage systems
  • Authenticator types: Email link, SMS OTP, or stronger KBA if required

Ensure Business Associate Agreements (BAAs) and retention controls are available; choose platforms with AES-256 at-rest encryption and TLS 1.2/1.3 in transit for protected health information.

Essential data elements to capture

Patient ID: Full legal name
Date of service: MM/DD/YYYY
Provider ID: NPI or provider number
Insurance info: Carrier and member ID
Cost estimate: Itemized or bundled amount
Signature: Signed name and date

Consequences of incorrect or missing forms

Balance billing risk: Patient billed improperly
Civil penalties: Regulatory fines possible
Claim denial: Payer may delay or deny reimbursement
Dispute delays: Longer resolution timelines
HIPAA exposure: Improper disclosures risk violation
Reputational harm: Patient trust erosion

Common preparation and submission errors

  • Incomplete payer information: sending a form without accurate carrier or member ID often causes routing failures and claim rejections.
  • Vague cost estimates: using non-itemized or unclear estimates increases disputes and undermines the form's protective intent.
  • Missing patient acknowledgement: failure to capture a dated signature or recorded consent can complicate downstream billing disputes.
  • Improper retention: discarding audit trails or not preserving signed copies can prevent defense in regulatory reviews or appeals.

eSignature vendor pricing and basic feature comparison

Compare common pricing and capability dimensions across vendors; signNow appears first and is shown with its starting price and plan notes.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes (Premium) Varies Varies Varies Varies
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA available) Yes (BAA available) Yes (BAA available) Varies Varies

Practical tips for accurate and efficient completion

Adopt consistent templates, validate payer data, and capture robust audit trails to reduce disputes and administrative burden.

Use standardized templates
Standardize the form across units to ensure consistent fields and avoid missing data; templates reduce variation and speed completion while improving auditability.
Automate payer lookup
Integrate real-time payer and network queries into intake systems to reduce errors in carrier and plan identification and lower claim rejection rates.
Capture strong authentication
Require at minimum an email or SMS OTP for patient acknowledgment; use higher-strength methods for disputed or high-dollar services to improve attribution.
Preserve audit evidence
Store signed PDFs, certificates of completion, IP addresses, and time stamps in tamper-evident storage for the full retention period required by HIPAA and recordkeeping rules.

Typical timing considerations to track

Track key dates from scheduling through billing to ensure notices are timely and documented.

At scheduling:

Provide a good-faith estimate when the patient schedules a non-emergency service.

Pre-service confirmation:

Reconfirm estimates and network status if there are changes before the service date.

At service:

Document any variance between estimate and actual billed charges.

Post-service notice:

Send final billing and explanation of benefits promptly after claims processing.

Dispute window:

Allow a clear process and timeline for patient disputes and payer responses per internal policy.

Frequently asked questions about the form and e-signature use

Answers to common questions about legal validity, HIPAA, corrections, and electronic submission of the Healthcare No Surprises Act Form.


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