Tip for NSA Notice & Consent

You are NEVER required to sign this consent — you can always refuse and request an in-network provider

Tip for NSA Notice & Consent

This notice CANNOT be used for emergency services, ancillary services (anesthesiology, radiology, pathology), or services where no in-network alternative is available

Tip for NSA Notice & Consent

Read the notice carefully — it must list the specific services and the estimated out-of-network charges

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Notice and Consent for Out-of-Network Services

NSA Notice & Consent · Providers (per No Surprises Act)

Written notice and consent form allowing a provider to balance-bill a patient for certain non-emergency out-of-network services at an in-network facility. Patient must receive notice 72 hours before the service and consent in writing.

Form Details

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Where to Submit This Form

🏢

Provided to you by the out-of-network provider at least 72 hours before a scheduled service

The provider must give you this notice AND obtain your written consent to waive surprise billing protections.

Filing Deadline

Must be provided at least 72 hours before the scheduled service (or same day for services scheduled within 72 hours).

Required Attachments

📎 Your signature on the consent form (if you agree to waive protections)
📎 No other attachments required from you

Processing Time

Immediate. Signing the consent means you agree to be billed at the out-of-network rate for the listed services.

What Happens Next

If you sign, you waive your No Surprises Act protections for the specific services listed. If you do NOT sign, the provider must bill you at the in-network rate (or find an in-network alternative). You can ALWAYS refuse to sign.

Tips for This Form

✓ You are NEVER required to sign this consent — you can always refuse and request an in-network provider
✓ This notice CANNOT be used for emergency services, ancillary services (anesthesiology, radiology, pathology), or services where no in-network alternative is available
✓ Read the notice carefully — it must list the specific services and the estimated out-of-network charges
✓ If you feel pressured to sign, file a complaint with CMS and your state Department of Insurance

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Providers (per No Surprises Act) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.