No Surprises Act Consent Form Template: Billing Waiver Notice

NO SURPRISES ACT CONSENT FORM TEMPLATE FAQ

What is a No Surprises Act consent form?

A No Surprises Act consent form is the written notice-and-consent document used when an eligible out-of-network provider or facility wants to ask a patient to waive certain federal surprise billing protections in a limited set of situations. HHS/CMS explains that this exception is available only in certain non-emergency situations at participating facilities and in certain post-stabilization situations after emergency care, if all required conditions are met.

Why do you need a No Surprises Act consent form?

You need this form when a provider or facility is lawfully trying to use the notice-and-consent exception and must document the patient’s written choice, the out-of-network status, and a good faith estimate of charges. Federal rules also require the notice to make clear that consent is optional and that the patient may instead seek care from an available participating provider, when applicable.

When should you use a No Surprises Act consent form?

Use this form only before the covered items or services are furnished and only when notice-and-consent is legally available. The form is not allowed for emergency services before stabilization, for non-emergency ancillary services, or for items and services arising from unforeseen urgent medical needs at the time care is furnished. Federal timing rules also require notice at least 72 hours in advance for appointments scheduled at least 72 hours ahead, on the scheduling date for appointments made within 72 hours, and at least 3 hours before same-day services.

How to write a No Surprises Act consent form?

Start by identifying the provider or facility, the patient or authorized representative, and the specific out-of-network items or services involved. Then include the provider’s out-of-network status, a good faith estimate of what the patient could pay, a statement that prior authorization or other care management limits may apply, and clear language that signing is optional. The consent should be signed before services are furnished and should document when the notice was given and when the consent was signed.

Can AI Lawyer help if patients, providers, and compliance staff all need to review?

AI Lawyer can help by organizing the form into clear sections so each reviewer can quickly find the out-of-network disclosure, the service description, the good faith estimate, the optional waiver language, and the signature timing. It can also add placeholders for state-specific wording, interpreter assistance, authorized representative details, and estimate attachments. A consistent structure helps reduce repeated edits and lowers the chance of missing key compliance details before the form is presented for signature.

No Surprises Act Consent Form Template

Compliance Note: This template should be used only where the No Surprises Act notice-and-consent exception is legally available. Federal rules require the HHS-specified form and timing requirements unless a compliant state-developed form controls, and notice-and-consent is not permitted in several categories of care, including pre-stabilization emergency services and non-emergency ancillary services.