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OMB Control Number: 09381401Surprise Billing Protection NotificationThisdocumentdescribesyourprotectionsagainstunexpectedmedicalbills. Italso asks if you would like to give up those protections and pay more for outofnetwork care.IMPORTANT: You may be given a form to sign if you are requesting outofnetwork care.
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Forms Surprise Protection Notification is a document used to inform individuals about their rights and protections under specific regulations or laws regarding surprise medical bills.
Healthcare providers and facilities that are involved in delivering services that may result in surprise medical billing are required to file this form.
To fill out the form, gather necessary patient information, service details, and ensure to comply with all required sections based on the guidelines provided by the regulatory authority.
The purpose of the form is to ensure transparency and give patients notice regarding their potential financial responsibilities and available protections against unexpected medical costs.
The form must report patient information, service details, provider information, estimated costs, and any applicable disclaimers regarding coverage.
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