Is there a form that I can send to my patients to comply with the ''No Surprises Act''?

Yes, Luminello provides an editable template that can be sent to any of your patients, provided they already have a portal account. See below where to find and how to edit this template to your liking: 

1. From your main dashboard, click on "Practice." 

2. Select "My Luminello Forms" from the "Practice" drop-down. 

3. Scroll down to the form titled "No Surprise Act - CUSTOMIZE FIRST!!" and click on the "Clone" icon to clone the form. 

4. Click on the "Edit" icon to edit your cloned form. 

Note: See this article to learn how to edit the questions and answers that show up in a custom form, please.

There are two ways you can edit this form:

Step 1: Involves customizing the form for your practice without specific patient/client info. Make sure to:

• On page 2, enter your name in the  ''Out-of-network provider(s) or facility name:'' field.
• On page 2, in the ''Questions about this notice and estimate?'' field, 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.
• On page 3, in the ''With my signature, I am saying that I agree to get the items or services from (select all that apply):'' field, enter either your name or facility name, and, in case consent is for multiple clinicians, add a checkbox for each one.  
• On page 4, enter your name in the ''Out-of-network provider(s) or facility name:'' field.

Step 2: Involves customizing the form for a specific patient/client. Make sure to: 

• On page 2, enter the patient's name and the total cost estimate of what they may be asked to pay. 
• On page 2, in the ''Questions about your rights?'', enter contact information for the appropriate federal or state agencies.
• On page 2, in the ''Prior authorization or other care management limitations'' section, enter either 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 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 to cover an item or service before you get them. If prior authorization is required, ask your health plan for the necessary information 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 can furnish the items or services described in this notice]
• On page 2, in the ''More information about your rights and protections'' field, enter the URL for the website where the patient can find more information about their rights under federal law. 
• On page 4, enter the patient's name. 

If you have any questions, please contact us.