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.