The NYS surprise bill certification form is a one-page document you send to your health plan and the out-of-network provider to formally declare that a medical bill qualifies as a surprise bill under New York law. Once both parties receive it, the provider cannot charge you more than your in-network copayment, coinsurance, or deductible. You can download it from the New York Department of Financial Services at dfs.ny.gov/IDR and submit it by mail or through your insurer’s portal.
When You Need to File the Form
Whether the form is required depends on how the surprise bill arose and when you received the care.
- If your in-network doctor referred you to an out-of-network provider without getting your written consent acknowledging that the referral could lead to uncovered costs, you must send the certification form to your health plan and the provider. This applies regardless of the date of service.
- If an out-of-network provider treated you at an in-network hospital or ambulatory surgical center and the date of service was before January 1, 2022, you must send the form.
- If that same in-facility situation happened on or after January 1, 2022, the form is not required, but DFS recommends sending it anyway so both your plan and the provider have written notice that the bill is protected.
Emergency services are a separate track. Under Section 606 of the Financial Services Law, an out-of-network provider cannot bill you more than your in-network cost-sharing for emergency care, and the hold-harmless protection applies automatically. No certification form is needed.
Even when the form is optional, filing it builds a paper trail. If the provider later tries to collect the balance, a signed and dated certification makes your case straightforward.
What Counts as a Surprise Bill
New York Financial Services Law Article 6 defines a surprise bill as a charge for non-emergency services in one of three situations.
The first is treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center when no in-network provider was available, when the out-of-network provider treated you without your knowledge, or when unforeseen needs arose during the procedure. A common example is an out-of-network anesthesiologist or radiologist you never chose. The protection does not apply if an in-network provider was available and you voluntarily chose the out-of-network one.
The second is referrals. If an in-network physician referred you to an out-of-network provider and you never signed a written acknowledgment that the referral might result in uncovered costs, the resulting bill qualifies.
The third covers uninsured patients who received care from a physician at a hospital or ambulatory surgical center without the cost disclosures required under Public Health Law Section 24.
How to Fill Out the Form
Download the form from the DFS surprise bill page at dfs.ny.gov/IDR, listed under “Sign a Surprise Bill Certification Form.” Have your insurance card and the disputed bill in front of you before you start.
Patient and Insurance Information
Enter your full name, mailing address, the date you received the service, your insurer’s name, and your insurance ID number exactly as it appears on your card. A mismatched ID number is the easiest way to delay things, so check it twice.
Provider Information
Fill in the out-of-network provider’s name, phone number, and mailing address. The form also has fields for a provider contact name (if different from the billing provider) and a contact email. All of this is on the bill itself or available from the provider’s billing office.
Certification Checkbox
The form has two checkboxes, and you pick one. The first is for patients: by checking it, you certify that you received services that qualify as a surprise bill and you are assigning the provider to seek payment directly from your health plan. The second is for health care providers filing the form on behalf of a patient for in-facility surprise bills with a date of service on or after January 1, 2022.
Most patients check the first box. Doing so directs your insurer to pay the provider, and the provider must accept whatever the insurer pays, plus your in-network cost-sharing, as payment in full.
Signature and Fraud Warning
Sign and date the form at the bottom. The fraud warning above the signature line states that knowingly filing a false claim is a crime and can result in a civil penalty of up to $5,000 per violation plus the stated value of the claim. It is standard New York insurance language; be truthful that the bill genuinely qualifies and you have nothing to worry about.
How to Submit It
Send a signed copy of the form to both your health plan and the provider who issued the bill, with a copy of the bill attached to each. DFS specifically instructs you to send it to both parties. Sending it to only one will not fully activate your protections.
Certified mail with a return receipt gives you proof of delivery, which matters if the provider later claims nothing arrived. Many insurers also accept submissions through online member portals or by fax, which is usually faster. Keep the original signed form and your mailing receipts in your own files.
If you have questions, DFS runs a consumer helpline at (800) 342-3736.
What Happens After You Submit
Once both parties receive the certification, the provider is prohibited from billing you for anything beyond your in-network copayment, coinsurance, or deductible. Under Financial Services Law Section 606, the provider must hold you harmless from the balance.
Your health plan then pays the provider directly or negotiates the amount. If the two sides cannot agree, either can submit the dispute to an independent dispute resolution entity, whose decision is binding on everyone involved. You stay out of that fight. Throughout the whole process you owe nothing more than your normal in-network cost-sharing.
If the Provider Keeps Billing You
A provider who continues sending balance bills after receiving your certification is violating state law. File a complaint with DFS through the online complaint portal at dfs.ny.gov/complaint or by calling (800) 342-3736. You can also contact the New York Attorney General’s office, which handles surprise billing enforcement.
Keep every bill the provider sends after you submitted the form. The dates on those bills, compared against your certified mail receipt, make the violation easy to document. Most providers stop once the certification arrives, but the paper trail is what protects you if yours doesn’t.
When the Form Won’t Help
A few situations fall outside these protections. If your employer or union self-funds your health coverage rather than buying it from an insurance company, the federal No Surprises Act governs instead of New York law, and disputes run through federal channels rather than DFS. Check your plan documents or ask your benefits administrator if you are not sure which type of plan you have.
Ground ambulance bills are the most notable gap in the federal law, though New York provides certain state-level protections against ground ambulance balance billing. Air ambulance services are covered under the federal law. Standalone dental and vision plans that qualify as “excepted benefits” are generally outside both the federal and New York protections.
The form also will not help if you voluntarily chose an out-of-network provider when an in-network one was available, or if you signed a valid notice-and-consent waiver before a non-emergency procedure acknowledging in writing that you understood the provider was out-of-network and agreed to pay out-of-network rates.