N.J. Stat. Ann. § 45:9-22.6

3. The written disclosure form required pursuant to section 2 of P.L.1989, c.19 (C.45:9-22.5) shall be prescribed by regulation of the State Board of Medical Examiners. In addition to such other information as the board determines necessary, the disclosure shall inform the patient whether any services or facility fees associated with the referral will be considered to be, and reimbursed at, an "out-of-network" level by the patient's insurance carrier or other third party payer.