OMB Control Number: 0938-1401
Expiration Date: 05/31/2025
Standard Notice and Consent Documents Under the No Surprises Act
(For use by nonparticipating providers and nonparticipating emergency facilities beginning January 1, 2022)
The Department of Health and Human Services (HHS) developed standard notice and consent documents under section 2799B-2(d) of the Public Health Service Act (PHS Act). These documents are for use when providing items and services to participants, beneficiaries, enrollees, or covered individuals in group health plans or group or individual health insurance coverage, including Federal Employees Health Benefits (FEHB) plans by either:
• A nonparticipating provider or nonparticipating emergency facility when furnishing certain post-stabilization services, or
• A nonparticipating provider (or facility on behalf of the provider) when furnishing nonemergency services (other than ancillary services) at certain participating health care facilities. Providers and facilities should NOT give these documents to an individual:
• Who is seeking items or services from in-network providers only,
• Who has Medicare, Medicaid, or any form of coverage other than as previously described, or
• Who is uninsured.
These documents provide the form and manner of the notice and consent documents specified by the Secretary of HHS under 45 CFR 149.410 and 149.420. HHS considers use of these documents in accordance with these instructions to be good faith compliance with the notice and consent requirements of section 2799B-2(d) of the PHS Act, provided that all other requirements are met. To the extent a state develops notice and consent documents that meet the statutory and regulatory requirements under section 2799B-2(d) of the PHS Act and 45 CFR 149.410 and 149.420 with respect to both form and manner of delivery, the state-developed documents will meet the federal specifications regarding the form and manner of the notice and consent documents.
These documents may not be modified by providers or facilities, except as indicated in brackets or as may be necessary to reflect applicable state law. To use these documents properly, the nonparticipating provider or facility must fill in any blanks that appear in brackets with the appropriate information. Providers and facilities must fill out the notice and consent documents completely and delete the bracketed italicized text before presenting the documents to patients. OMB Control Number: 0938-1401 Expiration Date: 05/31/2025 In particular, providers and facilities must fill in the blanks in the “Estimate of what you could pay” section and the “More details about your total cost estimate” section before presenting the documents to patients. The standard notice and consent documents must be given physically separate from and not attached to or incorporated into any other documents. The documents must not be hidden or included among other forms, and a representative of the provider or facility must be physically present or available by phone to explain the documents and estimates to the individual, and answer any questions, as necessary. The documents must meet applicable language access requirements, as specified in 45 CFR 149.420. The provider or facility is responsible for translating these documents or providing a qualified interpreter, as applicable, when necessary to meet those requirements.
The standard notice must be provided on paper, or, when feasible, electronically, if selected by the individual or authorized representative. The individual or authorized representative must be provided with a copy of the signed consent document inperson, by mail or via email, as selected by the individual or authorized representative.
If an individual makes an appointment for the relevant items or services at least 72 hours before the date that the items and services are to be furnished, these notice and consent documents must be provided to the individual, or the individual’s authorized representative, at least 72 hours before the date that the items and services are to be furnished. If the individual makes an appointment for the relevant items or services within 72 hours of the date the items and services are to be furnished, these notice and consent documents must be provided to the individual, or the individual’s authorized representative, on the day the appointment is scheduled. In a situation where an individual is provided the notice and consent documents on the day the items or services are to be furnished, including for post-stabilization services, the documents must be provided no later than 3 hours prior to furnishing the relevant items or services.
NOTE: The information provided in these instructions is intended to be only a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.
DO NOT INCLUDE THESE INSTRUCTIONS WITH THE STANDARD NOTICE AND CONSENT DOCUMENTS GIVEN TO PATIENTS.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1401. The time required to complete this information collection is estimated to average 1.3 hours per OMB Control Number: 0938-1401 Expiration Date: 05/31/2025 response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-2605, Baltimore, Maryland 21244-1850.
Surprise Billing Protection Form
OMB Control Number: 0938-1401
Expiration Date: 05/31/2025
This document describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of-network care.
IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.
You’re getting this notice because this provider or facility isn’t in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills when:
• You’re getting emergency care from an out-of-network provider or facility, or
• An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill. Ask your health care provider or patient advocate if you’re not sure if these protections apply to you. If you sign this form, be aware that you may pay more because:
• You’re giving up your legal protections from higher bills.
• You may owe the full costs billed for the items and services you get.
• Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit.
Contact your health plan for more information. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.
See the next page for your cost estimate.
1 OMB Control Number: 0938-1401
Expiration Date: 05/31/2025
Estimate of what you could pay
Out-of-network provider(s)or facility name:_______________________________________________ _____________________________________________________________________________________
Total cost estimate of what you may be asked to pay: $____________
►Review your detailed estimate. See Page 4 for a cost estimate for each item or service you’ll get.
►Call your health plan. Your plan may have better information about how much you’ll be asked to pay. You also can ask about what’s covered under your plan and your provider options.
►Questions about this notice and estimate? Contact [Enter contact information for a representative of the provider or facility to explain the documents and estimates to the individual, and answer any questions, as necessary.]
►Questions about your rights? Contact [Insert contact information for appropriate federal or state agency. The federal phone number for information and complaints is: 1-800-985-3059] Prior authorization or other care management limitations
[Enter either (1) specific information about prior authorization or other care management limitations that are or may be required by the individual’s health plan or coverage, and the implications of those limitations for the individual’s ability to receive coverage for those items or services, or (2) include the following general statement:
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover the items or services before you can get them. If your plan requires prior authorization, ask them what information they need for you to get coverage.] [In the case where this notice is being provided for post-stabilization services by a nonparticipating provider within a participating emergency facility, include the language immediately below and enter a list of any participating providers at the facility that are able to furnish the items or services described in this notice]
Understanding your options
You can get the items or services described in this notice from the following providers who are in-network with your health plan: More information about your rights and protections Visit [Insert website describing federal protections, such as _________________________ www.cms.gov/nosurprises/consumers] for more information about your rights under federal law.
2 OMB Control Number: 0938-1401 Expiration Date: 05/31/2025
By signing, I understand that I’m giving up my federal consumer protections and may have to pay more for out-of-network care. With my signature, I’m agreeing to get the items or services from (select all that apply):
☐ [doctor’s or provider’s name] [If consent is for multiple doctors or providers, provide a separate check box for each doctor or provider] ☐ [facility name] With my signature, I acknowledge that I’m consenting of my own free will and I’m not being coerced or pressured. I also acknowledge that:
• I’m giving up some consumer billing protections under federal law.
• I may have to pay the full charges for these items and services, or have to pay additional outof-network cost-sharing under my health plan.
• I was given a written notice on [enter date of notice] that explained my provider or facility isn’t in my health plan’s network, described the estimated cost of each service, and disclosed what I may owe if I agree to be treated by this provider or facility.
• I got the notice either on paper or electronically, consistent with my choice.
• I fully and completely understand that some or all of the amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
• I can end this agreement by notifying the provider or facility in writing before getting services. IMPORTANT: You don’t have to sign this form. If you don’t sign, this provider or facility might not treat you, but you can choose to get care from a provider or facility that’s in your health plan’s network.
_______________________________________ or ___________________________________________
Patient’s signature Guardian/authorized representative’s signature _______________________________________ ___________________________________________
Print name of patient Print name of guardian/authorized representative
Date and time of signature
Take a picture and/or keep a copy of this form. It contains important information about your rights and protections. 3 More details about your total cost estimate OMB Control Number: 0938-1401 Expiration Date: 05/31/2025
Patient name: __________________________________________________________________________
Out-of-network provider(s)or facility name:_________________________________________________ _______________________________________________________________________________________
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate. Contact your health plan to find out if your plan will pay any portion of these costs, and how much you may have to pay out-of-pocket. [Enter the good faith estimated cost for the items and services that would be furnished by the listed provider or facility plus the cost of any items or services reasonably expected to be provided in conjunction with such items or services. Assume no coverage would be provided for any of the items and services.] For each provider or facility described in the notice, fill-in the table below by completing each column for each item and service to be provided by the provider or facility. Add additional rows if necessary. If the notice is for more than one facility or provider, list items and services to be provided by the same facility or provider in adjacent rows, and provide a subtotal estimate for each facility and provider(s). If the notice is for one facility or one provider, the subtotal estimate may be omitted. The total amount on page 2 must be equal to the total of each of the cost estimates included in the table.] Date of service Name of Provider or Facility Service code Description Estimated amount to be billed Subtotal for [insert name of provider or facility]: Total estimate of what you may owe: