[Provider or Facility Name]
[Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
Date: [Date]
Subject: No Surprises Act Consent Form
This form is provided by:
Provider or Facility Name: [Full Legal Name]
Provider Type: [Out-of-Network Provider / Out-of-Network Emergency Facility / Other Eligible Party]
Department or Location: [Department / Unit / Office]
Contact Person: [Name and Title]
Phone Number: [Phone Number]
Email Address: [Email Address]
Patient Name: [Full Name]
Date of Birth: [Date of Birth]
Address: [Street Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
If signed by an authorized representative:
Representative Name: [Full Name]
Relationship to Patient: [Relationship]
Authority Under State Law: [Describe]
Health Plan or Coverage Name: [Plan Name]
Member ID Number: [ID Number]
Group Number, if applicable: [Group Number]
The provider or facility identified above is:
☐ Out-of-network for this plan or coverage
☐ Believed to be out-of-network for this plan or coverage
☐ Out-of-network status confirmed as follows: [Describe]
4. Eligible Items or Services
The patient is being offered the following items or services:
[Describe the specific out-of-network items or services]
Scheduled Date of Service: [Date]
Scheduled Time of Service: [Time]
Service Location: [Location]
This request for notice and consent is being used for:
☐ Eligible non-emergency items or services at a participating health care facility
☐ Eligible post-stabilization services after emergency care
☐ Other eligible circumstance permitted by applicable law: [Describe]
5. Notice of Out-of-Network Status
You are receiving this form because the provider or facility identified above is out-of-network for your health plan or coverage.
If you receive the listed items or services from this out-of-network provider or facility and sign this form, you may give up certain federal protections that would otherwise limit what you can be billed for those items or services.
6. Good Faith Estimate of What You Could Pay
Estimated charges for the listed items or services:
Provider or Facility Estimated Charges: $[Amount]
Estimated Charges for Related Items or Services Reasonably Expected to Be Furnished Together: $[Amount]
Estimated Total: $[Amount]
More details about the estimate:
[Describe the estimate, assumptions, expected related services, and any important pricing notes]
This estimate is provided in good faith based on information known at this time. It is not a guarantee of final charges and does not by itself create a contract for treatment.
7. Patient Options and Important Disclosures
Before deciding whether to sign this form, please understand the following:
-
You are not required to sign this form.
-
If you do not sign, you may be able to seek care from an available in-network provider or facility, where applicable.
-
If you sign, you may agree to receive out-of-network care and may pay more than you would have paid for in-network care.
-
Amounts you pay may not count toward your in-network deductible or out-of-pocket maximum.
-
Prior authorization or other care-management limits may apply to the listed items or services.
You are not required to sign this form.
If you do not sign, you may be able to seek care from an available in-network provider or facility, where applicable.
If you sign, you may agree to receive out-of-network care and may pay more than you would have paid for in-network care.
Amounts you pay may not count toward your in-network deductible or out-of-pocket maximum.
Prior authorization or other care-management limits may apply to the listed items or services.
Additional option details:
[Insert any plan-contact information, participating-provider alternatives, or required state-specific language]
8. Patient Acknowledgment
By signing below, I acknowledge that:
-
I received notice that the provider or facility listed above is out-of-network for my plan or coverage.
-
I received a good faith estimate of what I could pay for the listed items or services.
-
I understand that signing this form is optional.
-
I understand that I may be balance billed for the listed eligible items or services if I sign this form.
-
I understand that amounts I pay may not apply toward my in-network deductible or out-of-pocket limit.
-
I understand that this form applies only to the items or services identified in this document.
I received notice that the provider or facility listed above is out-of-network for my plan or coverage.
I received a good faith estimate of what I could pay for the listed items or services.
I understand that signing this form is optional.
I understand that I may be balance billed for the listed eligible items or services if I sign this form.
I understand that amounts I pay may not apply toward my in-network deductible or out-of-pocket limit.
I understand that this form applies only to the items or services identified in this document.
9. Consent to Receive Eligible Out-of-Network Care
I voluntarily consent to receive the eligible out-of-network items or services identified in this form.
I understand that by signing this form, I may be giving up certain federal surprise billing protections for the listed items or services, to the extent permitted by law.
I understand that this consent may not be valid if the law does not allow notice-and-consent for the listed services or if required form, timing, language, or delivery rules were not satisfied.
10. Timing Record
Date Notice Provided: [Date]
Time Notice Provided: [Time]
Method Notice Provided:
☐ Paper copy
☐ Electronic copy selected by patient or representative
☐ In-person explanation provided
☐ Phone explanation available
☐ Other: [Describe]
Date Consent Signed: [Date]
Time Consent Signed: [Time]
Scheduled Date of Service: [Date]
Scheduled Time of Service: [Time]
11. Language Assistance
Preferred Language of Patient or Representative: [Language]
This form was provided in:
[Language]
Interpreter or language assistance details, if applicable:
[Interpreter Name / Qualified Interpreter / Other Assistance Provided]
12. Patient or Authorized Representative Signature
Signature: __________________________
Printed Name: [Full Name]
Role: [Patient / Authorized Representative]
Date: [Date]
Time: [Time]
13. Provider or Facility Representative Signature
I certify that this form was provided in connection with the items or services identified above and that the provider or facility completed the information required before presenting it for signature.
Signature: __________________________
Printed Name: [Full Name]
Title: [Title]
Date: [Date]
Time: [Time]
14. Copy Provided to Patient
A signed copy of this form was provided to the patient or authorized representative by:
☐ In person
☐ Mail
☐ Email
☐ Other: [Describe]
Date Copy Provided: [Date]
15. Optional Attachments
Attach if needed:
☐ Detailed cost estimate
☐ Related service estimate
☐ Participating provider alternatives
☐ State-required notice language
☐ Interpreter or language assistance record
☐ Other: [Describe]
