Transcription of Standard Notice and Consent Documents Under the No …
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Standard Notice and Consent Documents Under the No …
OMB Control Number: 0938-1401 Expiration Date: 03/31/2022 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 unde r se cti on 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-em
Do not include t hese instructions with the s tandard notice and consent d ocument s given to patients. Paperwork Reductionct A Statement According t o the Paperwork R eductio n Act of 1 995, no pe rsons a re require d to r espond to a collect ion of informa tion unless it displays a valid Office of Management and Budget (OMB) control number.
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