AACE Learning Center Professional Resources-Surprise Billing Acknowledgment

Pdf Summary

This document provides federal standard notice and consent forms under the No Surprises Act for use by nonparticipating providers and emergency facilities. Its purpose is to inform patients when they are receiving out-of-network care and, in certain situations, allow them to waive protections against surprise billing.<br /><br />Key points:<br />- The forms apply to specific cases only: post-stabilization services from nonparticipating emergency facilities/providers, or non-emergency services at participating facilities from nonparticipating providers.<br />- They should not be used for in-network-only care, Medicare, Medicaid, uninsured individuals, or other coverage types not covered by these rules.<br />- Providers must complete the forms fully, including cost estimates, before giving them to patients. The forms cannot be altered except where brackets indicate or as required by state law.<br />- The notice must be given separately from other documents, not hidden in paperwork, and a provider representative must be available to explain it and answer questions.<br />- Timing rules apply: the notice must generally be given at least 72 hours before care if scheduled that far in advance, or on the same day if scheduled within 72 hours; if given on the day of service, it must be at least 3 hours before treatment.<br />- The patient receives an estimate of total costs, may contact their health plan, and can choose in-network care instead.<br />- By signing, the patient gives up federal surprise billing protections and may owe full out-of-network charges; the form can be cancelled in writing before services are received.<br />- The document also includes Paperwork Reduction Act information and an OMB control number.

Meta Tag

Concept No Surprises Act

Concept Standard Notice and Consent Documents

Concept Surprise Billing

Concept Cost Estimate

Concept Out-of-Network Care

Keywords

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notice and consent

out-of-network care

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OMB control number

No Surprises Act

Standard Notice and Consent Documents

Surprise Billing

Cost Estimate

Out-of-Network Care