Form CMS-10780 Standard Notice and Consent

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

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 nonemergency 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 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. The individual must be provided with a copy of the
signed consent document in-person, by mail or via email, as selected by the individual.

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-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.

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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 outof-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.

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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.

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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.

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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:

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