No Surprise Act

Standard Notice and Consent Documents Under the No Surprises Act OMB Control Number: 0938-1401 Expiration Date: 03/31/2022

Surprise Billing Protection

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 ou tof-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.

To comply with the Good Faith Estimate requirements, all non-insured or self-paying individuals must be provided with a Good Faith Estimate. Non-insured or self-paying individuals are defined as clients who:

Do not have benefits for an item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer or a federal or state health care program or the Federal Employee Health Benefits Program;

Do have benefits for an item or service under a group health plan, or individual or group health insurance coverage offered by a health insurance issuer, but do not seek to submit a claim for such item or service; or

Are enrolled in short-term, limited-duration insurance, but are not also enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, federal or state health care program, or the Federal Employee Health Benefits Program.

 You have the right to receive a “Good Faith Estimate”
explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes
related costs like medical tests, prescription drugs, equipment, and
hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate
in writing at least 1 business day before your medical service or item.
You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith
Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit
www.cms.gov/nosurprises or call 919.412-5685.