Good faith estimate form

A good faith estimate form is the written cost disclosure that a provider gives uninsured and self-pay patients before a scheduled service. The No Surprises Act requires it, so patients see expected charges before care starts. The estimate is due within one to three business days of booking, depending on how far ahead the visit is.

This page gives you a free good faith estimate form to download, plus practical guidance on completing it correctly. For the wider billing picture, read our guide to self-pay patients.

Key takeaways

A good faith estimate form lists the expected charges for a scheduled service, and uninsured or self-pay patients must receive it before care.

A service booked 10 or more business days ahead needs the estimate within three business days. Booked three to nine business days ahead, it is due within one.

Each estimate needs patient details, itemized charges, diagnosis and service codes, provider NPIs and TINs, and four set disclaimers.

If a provider’s bill comes in at least $400 above its line on the estimate, the patient can start a federal dispute.

Practice software such as Pabau can send the estimate at booking and keep a dated copy in the patient record.

What is a good faith estimate form?

A good faith estimate form is an itemized document that tells self-pay patients what a planned service is expected to cost. Its purpose is to prevent surprise bills, so patients can compare expected charges against their budget before agreeing to care.

• Gives patients a clear cost picture before they commit.
• Gives providers a dated record that the estimate was issued.
• Gives billing teams a baseline to check the final claim against.

CMS publishes a sample good faith estimate that shows the expected layout, and most practices start from it.

Which law requires this estimate?

The No Surprises Act requires providers to give a good faith estimate to uninsured and self-pay patients who schedule a service or ask for one. The Act took effect in January 2022, and CMS publishes the guidance practices use to apply it.

The CMS No Surprises Act pages hold the current guidance, so check them before you finalize your process.

Which providers must issue an estimate?

Providers and facilities that schedule care for uninsured or self-pay patients are covered, subject to how the Act defines a covered service. In practice, that often includes private practice therapists, counselors, and social workers, as well as practices that treat self-pay patients.

• Private practice therapy and counseling
• Medical practices treating self-pay patients
• Med spas and aesthetic practices treating self-pay patients

Scope depends on the Act’s definitions, so confirm your position with a compliance advisor. If you run a therapy practice, our therapy invoice template can bill the same line items the estimate listed, so the two documents match.

How soon must the estimate go out?

You must provide the estimate within one or three business days of scheduling, depending on how far ahead the service is booked. A patient who asks for an estimate without booking gets one within three business days of asking.

Count business days, not calendar days, from the day the appointment is booked. A booking that feels two weeks away can still fall into the shorter window, so count it on a calendar rather than by feel.

Two worked deadline examples

Both examples assume a practice that is open Monday to Friday.

• Booked Monday for Friday of the following week: That visit is nine business days out. The estimate is due by Tuesday, one business day after booking.
• Booked Monday for a visit three weeks later: That visit is 15 business days out. The estimate is due by Thursday, three business days after booking.

The first case is the easier one to get wrong. Nine business days looks like a long lead time, yet it sits in the one-day window, as the chart below shows. Building the estimate into your booking step means it goes out on time whichever band applies.

What the form must include

A compliant good faith estimate form must list the patient’s details, the planned service, itemized expected charges, diagnosis and service codes, and each provider’s identifiers. It must also carry set disclaimers. These fields come from the federal rule, so treat them as a minimum rather than a checklist to trim.

• Patient name and date of birth
• A plain-language description of the primary service, with the scheduled date if one is set
• An itemized list of expected items and services, grouped by provider or facility
• Diagnosis codes and expected service codes, such as CPT or HCPCS codes, for each line
• The expected charge for each item or service
• The name, NPI, and taxpayer identification number (TIN) of each provider and facility, plus where the service will happen
• Any related services that will need separate scheduling and their own estimate

The form must also include four disclaimers. It must say that other services may be recommended and estimated separately. It must explain that the final charges may differ from the estimate.

It must tell the patient about their right to dispute a bill and how to start that process. It must also state that the estimate is not a contract and does not oblige the patient to receive care.

Diagnosis codes follow the ICD-10-CM system, so use the code set in force on the service date. Practices that bill these services can also use claims management features to keep codes consistent between the estimate and the claim.

What happens if the final bill is higher than the estimate?

If a provider or facility bills at least $400 more than its total on the estimate, the patient can start patient-provider dispute resolution. That federal process lets an independent reviewer decide what the patient pays.

• The threshold is per provider: Compare each provider’s or facility’s billed total with its own line on the estimate, not the grand total.
• The patient has 120 calendar days: The clock starts on the date of the initial bill.
• The patient pays a $25 fee: This administrative fee covers the dispute review.

Here’s how the threshold plays out. Say your estimate lists $1,200 for your services. A bill of $1,550 is $350 over, so the patient has no dispute right. A bill of $1,600 is exactly $400 over, so they do.

The cleanest defense is an estimate that already lists the likely add-ons. If a follow-up injection or a lab test is reasonably expected, put it on the form with its charge.

Recurring services and changes to the estimate

One estimate can cover a course of recurring services for up to 12 months. It must state the expected scope, frequency, and total number of sessions. A weekly therapy plan or a series of laser sessions fits this rule.

If the services, providers, or expected charges change before the visit, issue a new estimate. The patient must receive it at least one business day before the service.

Record keeping and notice requirements

Keep a copy of every estimate you issue. A patient can ask for any estimate issued in the last six years, so a filing system that loses old forms creates a compliance problem.

You must also tell patients that estimates are available. The notice has to appear in three places:

• Prominently on your website, where a search engine can find it
• In your office and wherever scheduling happens
• Orally, when a patient schedules or asks about cost

The estimate itself must be in writing, on paper or electronically, as the patient prefers. Use clear, plain language that a patient without billing knowledge can follow.

Using the free template

The Pabau template above is a PDF you can print, fill in by hand, or adapt for your own process. It covers patient details, diagnosis codes, scheduling status, and itemized charges for the convening provider and up to two co-providers.

Each provider block has fields for the NPI, TIN, and service location. If you’re unsure which NPI to list, check whether the provider bills as an individual or as an organization.

The disclaimer already covers all four required statements and explains how to start a dispute. Add your practice details, then have your compliance advisor review the finished version, since the template is a starting point, not legal advice.

After the visit, a superbill template gives self-pay patients the itemized codes and charges they need for out-of-network reimbursement.

How to complete a good faith estimate form, step by step

Work through the form in seven steps, starting with the deadline and finishing with a filed copy. This order keeps codes and charges aligned with the service you plan to deliver.

1. Check the booking date and note which deadline applies.
2. Enter the patient’s name, date of birth, and contact preference.
3. Record the scheduled date, the service, and where it will take place.
4. Add the diagnosis codes and the service or procedure codes.
5. Itemize the expected charge for each line, grouped by provider or facility.
6. Add each provider’s NPI and TIN, plus the four required disclaimers.
7. Send the estimate, collect the acknowledgment, and file a dated copy.

Check each figure against your current fee schedule before you issue it. Outdated prices are the fastest way to open a $400 difference between the estimate and the final bill.

Common mistakes to avoid

Most errors come from missing fields and miscounted deadlines rather than poor judgment. Watch for these patterns during every review.

• Missing identifiers: The form omits a provider’s NPI or TIN.
• Missing facility fees: The estimate covers only the professional fee.
• Counting calendar days: The estimate goes out after the business-day deadline for that booking.
• Lump-sum totals: Charges are not itemized, so the patient cannot check them.
• Incomplete disclaimers: The form skips the dispute-rights or not-a-contract statement.
• No reissue after a change: The plan changes, but the patient still holds the old estimate.

Each mistake is easy to catch on a second look but much harder to fix once the patient has been billed.

How Pabau helps you issue and track good faith estimates

On paper, a good faith estimate depends on someone remembering to send it, counting the deadline correctly, and filing the signed copy. Each of those manual steps is a chance to miss the window or lose the record.

Pabau, the practice management platform we build, attaches the estimate to the appointment instead. Its digital forms can go to the patient when they book, so the estimate arrives inside the deadline without a reminder. The signed copy then sits in the patient’s Client record, dated and easy to find six years later.

The codes on the estimate also carry through to billing. Pabau Scribe, our AI scribe, drafts session notes from the appointment, so the documented service matches the service you estimated.

Send every estimate on time, automatically

Pabau sends your good faith estimate when the patient books and keeps the signed copy in their record. You meet the deadline and can produce any estimate on request.

Book a demo

Conclusion

A good faith estimate only protects you if it goes out on time and matches the bill that follows. The deadline and the $400 threshold are where self-pay billing goes wrong, and both are predictable.

So treat the estimate as part of booking, not as paperwork after it. List the likely add-ons up front, reissue the form when the plan changes, and keep every signed copy. Patients see the cost before they commit, and you avoid disputes you could have prevented.

Book a demo to see how Pabau sends good faith estimates at booking and keeps them on file for self-pay patients.

Continue your research

Treating more self-pay patients? Self-pay patients covers pricing, payment options, and how to collect from patients without insurance.

Need to know which NPI goes on the form? Type 1 vs type 2 NPI explains when to list an individual provider’s number and when to list the organization’s.

Giving self-pay patients a receipt they can claim? Our free superbill template gives patients the itemized codes and charges they need for out-of-network reimbursement.

Want the wider billing picture? What is medical billing explains the steps from service to payment.

Need the compliance rules behind your records? Medical billing compliance covers the rules that apply to your documentation.

Frequently asked questions