A short form agreement for health care providers (including physicians and other billing practitioners) and facilities (including hospitals, freestanding emergency departments, and urgent care centers) to use where the facility agrees to provide the required disclosure information under the No Surprises Act (part of the Consolidated Appropriations Act, 2021 (CAA-21)) on behalf of the provider. This written agreement can be used as a stand-alone agreement between a provider and a facility or as an amendment to an existing agreement. This Standard Document is based on federal requirements. State law may impose additional relevant requirements that may need to be integrated into the agreement, but this document will be useful to providers and facilities in every state. This Standard Document has integrated notes with explanatory, drafting, and negotiating tips.