Good faith estimate template and generator
- Free, no sign-up
- Runs in your browser
- Nothing you type is sent or stored
This free good faith estimate template is for practices whose patients pay for care themselves. Type in the patient, the services you expect to provide and your fee for each. The page adds up the total and prints a one-page estimate with the notices the federal No Surprises Act asks for.
Who has to give a good faith estimate?
Under the No Surprises Act, every licensed health care provider must give a good faith estimate to a patient who is uninsured or who chooses not to use insurance for the care. The rule has applied since January 2022. It covers a solo cash-pay practice the same way it covers a hospital, because your patients are self-pay by definition.
You must also tell patients that estimates are available: in writing on your website and in your office, and out loud when someone books or asks what care will cost.
When is it due?
| Situation | Give the estimate |
|---|---|
| Visit booked at least 3 business days ahead | Within 1 business day of booking |
| Visit booked at least 10 business days ahead | Within 3 business days of booking |
| Patient asks for an estimate, or asks what care will cost | Within 3 business days of the request |
| Visit booked fewer than 3 business days ahead | Not required unless the patient asks |
If what you expect to provide changes, send an updated estimate at least 1 business day before the visit.
What must it include?
- The patient's name and date of birth.
- A plain-language description of the main service, and the date if it is booked.
- An itemized list of the services you reasonably expect to provide, with a service code and the expected charge for each.
- Diagnosis codes that apply. For a new patient there is often none yet, and the estimate can say so.
- Your name, NPI and tax ID, and the state and office where care will be given.
- A list of services that need separate scheduling and are not in this estimate.
- Four notices: other services may be recommended that are not listed; the figures are an estimate and actual charges may differ; the patient may dispute a bill that is substantially higher (at least $400 more than the estimate); and the estimate is not a contract.
The generator prints all four notices for you. The wording follows the federal model notice, including where the patient can start a dispute.
Recurring care and memberships
One estimate can cover care that repeats, such as monthly follow-ups in a program, for up to 12 months. List how many visits you expect and the charge for each. After 12 months, or if the plan changes, give a new one.
How to give it and keep it
- In writing. On paper or electronically, whichever the patient asks for. An electronic copy must be one they can save and print, which a PDF is.
- Through a safe channel. The estimate holds health information. Send it through your patient portal or secure messaging, not ordinary email. See which tools sign a BAA.
- In the record. The estimate is part of the medical record. Keep a copy, and be ready to give the patient any estimate from the last 6 years.
Once the visit is done and paid for, patients who want to claim from their insurer need a superbill. Use the free superbill generator.
Common questions
Do cash-pay practices have to give a good faith estimate?
Yes. The rule applies to every licensed provider when a patient is uninsured or is not using insurance for the care, which describes every patient of a cash-pay practice.
What happens if the bill is higher than the estimate?
If you bill at least $400 more than the estimate, the patient can start a federal dispute within 120 calendar days of the bill. They pay a $25 fee, and a reviewer decides what they owe. If something changes before the visit, send an updated estimate.
Is a good faith estimate a contract?
No. It does not oblige the patient to go ahead, and it does not cap your charges. It sets the figure a later bill is compared against.
Does a published price list count as a good faith estimate?
No. A price list helps patients, but the estimate has to be made out to the individual patient, with their name and date of birth, the services you expect for them and the required notices.
Does the generator use AI?
No. It is a form and a template. It fills a fixed layout with what you type and adds up the charges.
Is patient information saved or sent anywhere?
No. Everything stays in your browser tab. Nothing you type is sent to us, stored on a server or recorded, and it disappears when you close or reload the page.