REFERENCE / No Surprises Act Disclosure Notice Requirements

The No Surprises Act (NSA) requires providers and facilities to communicate consumer protections against balance billing.


A one-page disclosure notice made publicly available and posted on your website that uses clear and easily understood language to detail:

  • The NSA’s requirements for providers and facilities regarding balance billing for emergency services and non-emergency services
  • Applicable state law regarding patient charges
  • Contact information for the relevant state and federal agencies to discuss a potential violation of the above 


It must be given to individuals in health plans to which the NSA applies and to whom you provide items or services at or in connection with a visit at a healthcare facility


Provide the notice in-person, by mail or email, as selected by the individual.

Limit it to one-page (double-sided) and use a font size of 12 points or larger.


Issue the notice no later than the date and time on which you request payment from the individual (including requests for copayment or coinsurance made at the time of a visit to the provider or facility).

If payment isn’t requested, the notice must be provided no later than the date on which the provider or facility submits a claim for payment to the plan or issuer.


  • It’s important to remember this disclosure notice is different from the Notice & Consent form for non-emergency care billing and each CMS form serves different purposes.
  • Give careful thought to identifying every place where the model notice must be physically or electronically posted, and how and when patients will be given the notice during the revenue cycle.
  • States may create their own versions of this model disclosure notice, so we recommend each facility also check with its appropriate state regulatory authority.

For example, see Virginia’s version of the Model Disclosure Notice.

To learn more about complying with No Surprises Act operational requirements, read The Nuances of Operational Compliance Under the No Surprises Act.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional in regard to specific legal or compliance questions you have.