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OMB Control Number: 09381401 Expiration ExpirationDate: Date:12/31/2022 xx/xx/xxxxSurprise Billing Protection Form This document describes your protections against unexpected medical bills. It also

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How to fill out surprise billing protection form

01

Obtain the surprise billing protection form from your insurance provider or healthcare provider.

02

Fill out your personal information such as name, address, and insurance policy number.

03

Provide details of the medical services for which you are seeking protection from surprise billing.

04

Sign and date the form to confirm that the information provided is accurate.

05

Submit the completed form to the appropriate party as instructed.

Who needs surprise billing protection form?

01

Anyone who has received medical services from out-of-network providers and is at risk of being surprise billed.

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What is surprise billing protection form?

Surprise billing protection form is a document designed to protect consumers from unexpected medical bills.

Who is required to file surprise billing protection form?

Healthcare providers and insurance companies are required to file surprise billing protection form.

How to fill out surprise billing protection form?

To fill out the form, one must provide detailed information about the healthcare services provided and the insurance coverage.

What is the purpose of surprise billing protection form?

The purpose of the form is to ensure that consumers are not unfairly charged for out-of-network medical services.

What information must be reported on surprise billing protection form?

The form must include details about the healthcare provider, the services provided, and the insurance coverage.

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