Standard Notice and Consent Documents Under the No Surprises Act

Standard Notice and Consent Docume nts Unde r the No Surpris e s Act

Version 1: To be used in 2022 only

Ve rsion 2: To be use d in 2022 and be yond

Version 1: To be used in 2022 only

OMB Control Number: 0938-1401

Expiration Date: 05/31/2025

Standard Notice and Conse nt Docume nts Unde r the No Surprises Act

(For use by nonparticipating provide rs and nonparticipating e me rge ncy facilitie s

beginning January 1, 2022)

Instructions

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 individua ls in group health plans or group or individua l health insurance coverage,

including Federal Employees Health Benefits (FEHB) plans by either:

• A nonparticipating provider or nonparticipating emergency facility when furnishing

certain post-sta bilizat io n servic e s, or

• A nonparticipating provider (or facility on behalf of the provider) when furnishing non-

emergency services (other than ancillary services) at certain participating health care

facilities.

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, the state-developed documents will meet the Secretary’s 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.

In particular, providers and facilities must fill in the blanks in the “Estimate of what you may

pay” section and the “More details about your 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 individua l, 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 individua l.

The individual must be provided with a copy of the

signed consent document in-person, by mail or via email, as selected by the individua l.

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 individua l, or the individua l’s authorized representative, at least 72 hours

before the date that the items and services are to be furnished. If the individua l 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 individua l’s authorized representative, on the day the appointment is scheduled. In a situation

where an individua l is provided the notice and consent documents on the day the items or

services are to be furnished, including for post-sta bilizat io n 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 the se instructions with the standard notice and cons e nt docume nts given to

patie nts .

Pape rwork Re duction Act State ment

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-XXXX.

The time required to complete this information collection is estimated to average 1.3 hours per

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 C4-26-05,

Baltimore, Maryland 21244-1850.

Surprise Billing Protection Form

The purpose of this document is to let you know about your protections from

unexpected medical bills. It also asks whether you would 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 when you received 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. This means

the provider or facility doesn’t have an agreement with your plan.

Getting care from this provider or facility could cost you more.

If your plan covers the item or service you’re getting, federal law protects you from higher bills:

• When you get emergency care from out-of-network providers and facilities, or

• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical

center without your knowledge or consent.

Ask your health care provider or patient advocate if you need help knowing if these protections apply to

you.

If you sign this form, you may pay more because:

• You are giving up your protections under the law.

• You may owe the full costs billed for items and services received.

• 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.

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if

a doctor was assigned to you with no opportunity to make a change.

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, your health plan might work out an agreement with this provider

or facility, or another one.

See the next page for your cost estimate.

Estimate of what you could pay

Patient name:_________________________________________________________________________

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 will 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? Call [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 [contact information for appropriate federal or state agency]

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 an item or

service before you get them. If prior authorization is required, ask your health plan about what

information is necessary 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 also get the items or services described in this notice from these providers who are in-network

with your health plan:

More information about your rights and protections

Visit [website] for more information about your rights under federal law.

By signing, I give up my federal consumer protections and agree to

pay more for out-of-network care.

With my signature, I am saying that I agree 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 am consenting of my own free will and am not being coerced or

pressured. I also understand that:

• I’m giving up some consumer billing protections under federal law.

• I may get a bill for the full charges for these items and services, or have to pay out-of-network

cost-sharing under my health plan.

• I was given a written notice on [enter date of notice] explaining that my provider or facility isn’t

in my health plan’s network, the estimated cost of services, and 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 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. But if you don’t sign, this provider or facility might not

treat you. You can choose to get care from a provider or facility 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 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.

More details about your estimate

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 how much, if any, your plan will pay and how much you may have

to pay.

[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.].

[Populate the table below with each item and service, date of service, and estimated cost. Add additional

rows if necessary. 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

Service code

Description

Estimated amount

to be billed

Total estimate of what you may owe:

Version 2: To be used in 2022 and beyond

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)

Instructions

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 non-

emergency 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 in-

person, 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 C4-26-

05, Baltimore, Maryland 21244-1850.

OMB Control Number: 0938-1401

Expiration Date: 05/31/2025

Surprise Billing Protection Form

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.

OMB Control Number: 0938-1401

Expiration Date: 05/31/2025

Estimate of what you could pay if you give up your protections

Patient name:_________________________________________________________________________

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.

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 out-

of-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 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.

OMB Control Number: 0938-1401

Expiration Date: 05/31/2025

More details about your total cost estimate

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: