A model surprise medical billing protection disclosure notice for health care providers (including physicians and other billing practitioners) and facilities (including hospitals, freestanding emergency departments, and urgent care centers) to provide to patients as required under the No Surprises Act (part of the Consolidated Appropriations Act, 2021 (CAA-21)). This resource reflects interim final regulations (IFRs) issued in July 2021 and further guidance released in August 2022, to implement the No Surprises Act. This Standard Document is based on federal requirements. State law may impose additional relevant requirements that may need to be integrated into the disclosure notice, but this document will be useful to providers and facilities in every state. This Standard Document has integrated notes with important explanations and drafting tips.