# What should a med spa good faith estimate include?

Canonical: https://prospyrmed.com/resources/practice-answers/good-faith-estimate-template
Sources reviewed: 2026-09-16 · Prepared by Prospyr

Use the current CMS model and instructions for applicable uninsured/self-pay healthcare services. An estimate needs more than a package total: identify the patient, provider, expected items and services, expected charges and required disclosures. The downloadable worksheet helps gather inputs; it does not replace the official notice.

## Describe the expected care and charges

CMS explains that a good faith estimate includes expected charges for the scheduled healthcare items and services. Make the scope understandable and identify expected components rather than presenting an unexplained lump sum. Do not promise an exact final bill when the scope may change.

Source: [CMS: What is a good faith estimate?](https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/medical-bill-guides-resources/what-good-faith-health-insurance-estimate) — Estimate contents and patient guidance

## Preserve the explanation and version

Use the required federal content and disclosures, including information about the dispute process. As a practice workflow, retain the assumptions, staff reviewer, date issued and version delivered. An internal worksheet or price list alone is not evidence that the compliant estimate was provided.

Source: [CMS: No Surprises Act Part II rule, 45 CFR 149.610](https://www.cms.gov/files/document/cms-9908-ifc-surprise-billing-part-2.pdf) — Federal rule; recurring estimates and required disclosures

## Practical checklist

1. Confirm applicability and obtain the current CMS model instructions.
2. List anticipated services, quantities, provider details and charges.
3. Include the required disclosures and explain the scope.
4. Deliver the estimate on time and retain the version sent.

## Worked example

A treatment series quote lists only “package: $1,800.” The preparation worksheet should break down expected services, number of visits and included components before the team prepares the formal estimate. The example amount is illustrative and is not a recommended price.

## Mistakes to avoid

- Calling a blank worksheet an official CMS form.
- Leaving the expected number of visits undefined.
- Removing required dispute disclosures from a branded version.

## Related questions

- [When must a practice send a good faith estimate?](https://prospyrmed.com/resources/practice-answers/good-faith-estimate-deadlines)
- [Can one good faith estimate cover a treatment series?](https://prospyrmed.com/resources/practice-answers/recurring-treatment-estimates)
- [What happens if a self-pay bill is $400 above the estimate?](https://prospyrmed.com/resources/practice-answers/medical-bill-400-dispute)

Prepared by Prospyr from the cited primary sources. These are educational workflow resources, not individualized clinical, coding, legal or tax advice. No clinician, certified-coder or attorney review is claimed. Confirm current code instructions, payer terms and applicable law for the actual service and date. CPT is a registered trademark of the American Medical Association; this is not a substitute for a licensed current code set.