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Good faith estimate generator
Under the No Surprises Act, clinicians have to give self pay and uninsured patients a written estimate of what care will cost. Fill this in and print it. Everything runs in your browser, and nothing you type leaves this page or gets saved.
Good faith estimate
Prepared under the No Surprises Act, 45 CFR 149.610, for a patient who is uninsured or not using insurance for this care.
- Clinician
- Practice
- NPI and TIN
- Service location
- Patient
- Expected service
- Care expected to start
| Service | Code | Quantity | Each | Expected total |
|---|---|---|---|---|
| Total expected charges over 12 months | ||||
This good faith estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time it was created and does not include any unknown or unexpected costs that may arise during treatment.
If you are billed for more than this good faith estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed above to let them know the billed charges are higher than the good faith estimate. You can ask them to update the bill, negotiate, or ask if financial assistance is available.
You may also start a patient provider dispute resolution process with the U.S. Department of Health and Human Services. You must start the process within 120 calendar days of the date on the original bill, and there is a $25 fee to use the process. If the agency reviewing your dispute agrees with you, you will pay the price on this estimate.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.
Keep a copy of this good faith estimate in a safe place or take pictures of it.
This estimate is not a contract and does not obligate you to obtain the services listed.
This is a template and a calculator, not legal advice. Have your own counsel confirm it fits your state and your practice before you rely on it.
A few things worth knowing
The requirement applies to patients who are uninsured, and to insured patients who choose not to use their insurance for that care. Give the estimate in writing, and give it within the timeframe your practice type requires once care is scheduled or the patient asks for one.
You also have to notify patients that they have the right to one, in a place they will see it, which usually means your website, your waiting room, and your intake paperwork.
CMS publishes the current requirements at cms.gov/nosurprises. Rules change, so check there rather than trusting a template you found last year, including this one.