New York State Surprise Bill Website Template

Practis has received a number of calls and requests from clients to update their website to comply with this new law. In an effort to assist others in this process, we\'ve compiled some helpful information and a useful template to use when updating your site.

Of note, we would like to thank those who have shared this helpful information with us so that we can pass it along to others.

About the Surprise Bill

Effective March 31, 2015,  healthcare providers within New York State must comply with new disclosure requirements under the Surprise Bill Law for services that were referred by a participating physician to a non-participating provider.

Information to disclose includes the following:


  • Health plan participation
  • Hospital affiliation
  • Affiliated providers that you refer to (anesthesiologists, labs, radiology, assistant surgeons, etc).  Include contact information, link to their website.


  • List of the standard charges for items and services providef, including DRGs to the extent required by ACA
  • List of participating health plans
  • A statement that includes the following information:
    • physician services provided in the hospital are not included in the hospital charges
    • physicians who provide services in the hospital may or may not participate with the same health plans as the hospital
    • patients should check with the physician arranging for the hospital services to determine the plans with which the physician participates;
    • the name, address, and phone number of physician groups the hospital contracts with to provide services along with instructions on how to contact those groups to determine the health plans in which the physicians participate.
  • HANYS Hospital Disclosure Template - download here

Website Page Template

**Please copy and paste the content below to add it to your website.***

Understanding your bill

Understanding how your healthcare services are paid for can be confusing. At [Name of hospital/practice], our billing staff is happy to assist you with understanding the charges related to the medical services provided.

Health Insurance Plan Participation

[Name of practice/hospital] participates with the following health plans:

  • Health plan name
  • Health plan name
  • Health plan name

If your health plan is not listed above, please call your insurance company directly.

Hospital Affiliations

We maintain affiliations with the following hospitals:

  • [Name of hospital]

Services Billed Separately

Some of the services provided are not included in the charges billed by our [practice/hospital] and you may be billed separately for them. They include affiliated physicians, radiologists,labs and anesthesiologists. They may, or may not, participate with the same plans as [name of practice/hospital]. Please check with the affiliated provider below if you have questions regarding the insurance plans they participate with or a bill you may receive from them.

  • Affiliated provider
  • Affiliated provider
  • Affiliated provider


Have more questions? Submit a request