Who needs a Good Faith Estimate?
Any patient who is uninsured, or who has insurance but chooses not to use it (self-pay), must get a Good Faith Estimate from the provider scheduling their care.
Business Tools
Good Faith Estimate
Create No Surprises Act cost estimates for self-pay patients.
Built in your browser: patient details are never uploadedFree: 3 uses a day, 5 with a free account. Unlimited on Pro
1Provider and practice
Remembered in this browser. Sign in to keep it in your account instead.
Logo (optional)
Signature
2Patient
Never saved or uploaded. Cleared when you start the next estimate.
3Care being estimated
Describe the care in plain words. For recurring care such as therapy, one estimate can cover up to 12 months.
Diagnosis codes (if known)
4Items and services
Every item or service you expect to provide, with the price the patient will be charged.
Recurring visits:for 12 months = 52 visits
$0.00
DiagnosisAdd a diagnosis above if known
Other providers or facilities (optional)
Add a lab, imaging center, anesthesia or another provider who will bill the patient separately for this care.
5Estimate details
The required patient notices included on every estimate
Disclaimer. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. It does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.
Additional items and services. There may be additional items or services your provider recommends as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate.
If you are billed more than this estimate. You have the right to dispute the bill if you are billed at least $400 more than this Good Faith Estimate for any provider or facility listed. You may contact the provider or facility to tell them the billed charges are higher than the estimate, and ask them to update the bill, negotiate the bill, or tell you whether financial assistance is available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days (about 4 months) of the date on the original bill. A small administrative fee applies. If the agency reviewing your dispute agrees with you, you will pay the price on this Good Faith Estimate. If it agrees with the provider or facility, you will pay the higher amount. Starting a dispute will not affect the quality of care you receive.
More information. 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. You may need it if you are billed a higher amount.
This is not a contract. This Good Faith Estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities listed.
Check before you send (8)
- Add the provider or practice name.
- Add an NPI. The estimate must list the NPI of each provider.
- Add the Tax ID (TIN). The estimate must list it.
- Add the address where care will be given, including the state.
- Add the patient name and date of birth.
- Describe the primary service in plain words, for example "Weekly individual therapy".
- Add diagnosis codes if they are known. They are required when available.
- Add at least one item or service with a price.
Provider$0.00
Total estimate$0.00
How it works
1
Add your practice
Fill in from the NPI Registry and add your Tax ID. Sign in once and your practice fills in automatically every time.
2
Add the patient and care
Describe the care in plain words, add diagnosis codes, and list each service with its code, quantity and price.
3
Download and give it
The PDF includes every required notice. Give it to the patient and keep a copy for your records.
What is a Good Faith Estimate?
Since January 1, 2022, the No Surprises Act requires health care providers and facilities to give uninsured and self-pay patients a written estimate of expected charges before care. It is called a Good Faith Estimate. Patients have a right to it whether they ask or not, and it applies to therapists, counselors, physicians, dentists, chiropractors and most other licensed providers.
If the final bill is at least $400 more than the estimate for any provider or facility, the patient can dispute the bill through a federal process.
What a Good Faith Estimate must include
- Patient: name and date of birth.
- Primary service: a plain-language description of the main item or service, and the date if it is scheduled.
- Itemized list: each item or service you reasonably expect to provide, grouped by provider or facility, with the expected charge for each.
- Codes: diagnosis codes and expected service codes (CPT or HCPCS) where available.
- Providers: the name, NPI and Tax ID of each provider or facility, and the state and location where care will be given.
- Separately scheduled care: items or services expected before or after this care that will be scheduled and estimated separately.
- Required notices: that it is only an estimate, that it is not a contract, that additional services may not be included, and how to dispute a bill that is $400 or more above the estimate.
When to give a Good Faith Estimate
| Situation | Deadline |
|---|---|
| Care scheduled 3 to 9 business days ahead | Within 1 business day of scheduling |
| Care scheduled 10 or more business days ahead | Within 3 business days of scheduling |
| Patient asks for an estimate | Within 3 business days of the request |
Good Faith Estimates for therapists
Therapy is usually recurring, so one estimate can cover the visits you expect over a period of up to 12 months. List the intake session (for example 90791) and the ongoing sessions (for example 90834 or 90837) with the expected number of visits. If the plan changes, or the year ends, give a new estimate.
Keep a copy of every estimate you give. Many practices keep them for at least 6 years.
Good Faith Estimate features
- Covers every item the No Surprises Act asks for: patient, primary service, diagnosis codes, service codes, itemized costs, and the provider NPI, TIN and location.
- The required patient notices are added for you, including the $400 dispute right, the 120 day deadline, and where to get help.
- Recurring care in one step: pick how often (weekly, every 2 weeks, monthly) and the number of visits for the estimate period is calculated.
- Add other providers or facilities, such as a lab or imaging center, each with their own NPI, TIN, location and costs.
- Search all 2027 ICD-10-CM diagnosis codes and reuse your saved services and fees.
- Save your practice to your Craftora account so it fills in automatically on any computer. Patient details are never saved or uploaded.
- Logo, signature, estimate numbers and page numbers on longer estimates.
Good Faith Estimate FAQ
Is this Good Faith Estimate template free?
Yes. Create and download estimates without an account up to 3 times a day, or 5 times a day with a free account. Pro removes the daily limit.
Does it include the required disclaimers?
Yes. Every estimate includes the notices about it being an estimate, not a contract, possible additional services, and the patient right to dispute a bill that is $400 or more above the estimate, with the CMS website and phone number.
Can I save my practice details?
Yes. Sign in and save your practice once. It fills in automatically on any computer, in both the Good Faith Estimate and the Superbill Generator. Patient details are never saved or uploaded.
Can one estimate cover a year of therapy?
Yes. Set the estimate period, choose how often sessions happen, and the tool calculates the number of visits. Estimates for recurring care usually cover up to 12 months.
What is the difference between a Good Faith Estimate and a superbill?
A Good Faith Estimate is given before care and shows expected costs. A superbill is given after care, once the patient has paid, so they can ask their insurance for reimbursement. Craftora makes both from the same practice details.
Related Business Tools
Invoice GeneratorCreate and download professional PDF invoices for free.Superbill GeneratorCreate insurance-ready superbills with NPI lookup and ICD-10 codes.CMS-1500 Claim FormFill out and print the CMS-1500 (HCFA) insurance claim form.Letter of Medical NecessityWrite insurance, appeal and HSA/FSA medical necessity letters.
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