Free compliance & forms tool
Good Faith Estimate Template and Generator
A good faith estimate (GFE) is a written notice of expected charges that a practice gives an uninsured or self-pay patient on request or when a service is scheduled. Under 45 CFR 149.610 it lists the patient, the primary service, itemized charges by provider with service codes, NPI and tax ID, and five required disclaimers. It is due 1 to 3 business days after scheduling or request. The generator below builds the form and checks each element.
Prepared by Prospyr · Reviewed October 3, 2026 · Free, no sign-up, runs in your browser
The form starts with example data so you can see the finished estimate. Replace it with your own, or . Patient details stay in this browser tab and are never sent anywhere.
Estimate total $10,100.00 · 1 required element missing (see the check below the form)
Line total $2,400.00
Each separate provider or facility gets its own block, name, NPI and TIN. Ask each one for its charges within 1 business day of scheduling.
Total estimated cost, all providers and facilities
$10,100.00
Example Aesthetic Surgery PLLC$7,700.00
Example Surgery Center$2,400.00
45 CFR 149.610(c)(1) content check
1 required element still missing. 1 to review.
- Missing: Patient name and date of birth (c)(1)(i)
- Complete: Description of the primary item or service in clear language (c)(1)(ii)
- Complete: Itemized list of services, grouped by provider or facility (c)(1)(iii)
- Complete: Service code and expected charge for every item (c)(1)(iv)
- Review: Applicable diagnosis codes (c)(1)(iv)4 items without a diagnosis code. The CMS model form asks for one "if required for the calculation of the GFE", so leave it blank only when none applies.
- Complete: Name, NPI, TIN, state and location of each provider or facility (c)(1)(v)
- Added for you: Disclaimer above the list of separately scheduled items (c)(1)(vi)
- Added for you: Disclaimer: other recommended items may need separate scheduling (c)(1)(viii)
- Added for you: Disclaimer: estimate only, actual charges may differ (c)(1)(ix)
- Added for you: Dispute-process disclaimer and where to find instructions (c)(1)(x)
- Added for you: Disclaimer: not a contract (c)(1)(xi)
A template built from the CMS model form and 45 CFR 149.610. It does not verify codes, charges or your legal obligations; your compliance lead or counsel owns that.
Preview of the estimate your patient receives
Example Aesthetic Surgery PLLC
Good Faith Estimate for Health Care Items and Services
Patient: —
Date of birth: —
Account number (last four, optional): —
Contact preference: By email
Mailing address: —
Phone: —
Email: —
Primary service or item requested/scheduled: Breast augmentation with silicone implants (cosmetic), including related surgeon, implant and facility charges
Date(s) the primary service will be provided: Not yet scheduled
Date of this Good Faith Estimate: —
Summary of expected charges
| Provider or facility | Estimated total cost |
|---|---|
| Example Aesthetic Surgery PLLC | $7,700.00 |
| Example Surgery Center | $2,400.00 |
| Total estimated cost | $10,100.00 |
The following is a detailed list of expected charges for Breast augmentation with silicone implants (cosmetic), including related surgeon, implant and facility charges, as well as for items or services reasonably expected to be furnished in conjunction with the primary item or service as part of the period of care.
Convening provider or facility estimate: Example Aesthetic Surgery PLLC
Type: Physician practice
Contact: Front desk · (512) 555-0100 · frontdesk@example.com
Location where services will be provided: 100 Example Way, Suite 200 Austin, TX 78701
National Provider Identifier (NPI): 1234567893
Taxpayer Identification Number (TIN): 12-3456789
| Service or item | Service code | Diagnosis code | Qty | Expected cost |
|---|---|---|---|---|
| Surgeon fee: breast augmentation with implants | CPT: 19325 | 1 | $5,200.00 | |
| Breast implants, silicone (pair) | HCPCS: L8600 | 2 | $2,500.00 | |
| Post-operative visits (first 90 days) | Included in surgeon fee | 1 | $0.00 | |
| Total expected charges from Example Aesthetic Surgery PLLC | $7,700.00 | |||
Co-provider or co-facility 1 estimate: Example Surgery Center
Type: Ambulatory surgical center
Contact: Billing office · (512) 555-0111
Location where services will be provided: 200 Example Blvd Austin, TX 78702
National Provider Identifier (NPI): 1003000126
Taxpayer Identification Number (TIN): 98-7654321
| Service or item | Service code | Diagnosis code | Qty | Expected cost |
|---|---|---|---|---|
| Facility fee, operating room and recovery | Per facility schedule | 1 | $2,400.00 | |
| Total expected charges from Example Surgery Center | $2,400.00 | |||
Total estimated cost for all services and items: $10,100.00
Health care items and services expected to be separately scheduled with another provider or facility
DISCLAIMER: For health care items/services listed below, separate good faith estimates will be issued upon scheduling or upon request. Specific information such as the names and identifiers for the providers or facilities that may furnish the services, diagnosis codes (if required for the calculation of the GFE), service codes, and expected charges will be provided in separate good faith estimates once these items or services are scheduled (or upon request).
| Service or item | How to get a good faith estimate for it |
|---|---|
| Implant revision or removal, if ever needed | Ask our front desk, (512) 555-0100, for a separate good faith estimate once it is scheduled. |
Disclaimer
There may be additional items or services we recommend as part of your course of care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate.
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.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.
If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. The initiation of this process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
Questions about this estimate: Example Aesthetic Surgery PLLC, (512) 555-0100 · frontdesk@example.com.
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.
Good faith estimate form: the elements 45 CFR 149.610(c)(1) requires
A good faith estimate form for a self-pay patient has to include all of the following. The generator marks each one complete, missing or added for you as you type.
- Patient name and date of birth.
- The primary item or service in clear and understandable language, and its date if it is scheduled.
- An itemized list of items and services, grouped by provider or facility, for the whole period of care.
- Diagnosis codes, expected service codes and expected charges for each item.
- Name, NPI and TIN of each provider or facility, plus the state and office or facility location.
- A list of separately scheduled items, with a disclaimer directly above it explaining that separate estimates will follow and how to get them.
- Four more disclaimers: additional items may need to be scheduled separately; this is only an estimate; the right to dispute and where to find instructions; and the estimate is not a contract.
The estimate must be written, on paper or electronically, in a form the patient can save and print, and in language the average patient can understand. CMS publishes a model form (linked under sources). HHS treats use of the model notice as good-faith compliance with the content requirements.
No Surprises Act good faith estimate: when to deliver it
| Situation | Deliver within | Rule |
|---|---|---|
| Scheduled 10 or more business days before the service | 3 business days of scheduling | (b)(1)(vi)(B) |
| Scheduled 3 to 9 business days before the service | 1 business day of scheduling | (b)(1)(vi)(A) |
| Patient asks for an estimate | 3 business days of the request | (b)(1)(vi)(C) |
| Scope, charges or providers change | New estimate at least 1 business day before the service | (b)(1)(vii) |
| Recurring services (one estimate) | Valid up to 12 months; new estimate after that | (b)(1)(x) |
The convening provider, meaning the practice that schedules the primary service, is responsible for gathering charges from every co-provider or co-facility (anesthesia, a surgery center, a lab). It has to ask them within 1 business day of scheduling, and each has 1 business day to answer. Any discussion about price counts as a request, so a patient who asks "what will this cost?" has asked for an estimate.
The deadline helper counts Monday to Friday and does not skip federal holidays. It counts business days after the scheduling date up to and including the service date. Confirm how your counsel counts them if a deadline is close.
Worked example: a surgeon, a surgery center and a $400 gap
The tool opens on this example so you can see every part of the finished estimate.
| Provider or facility | Item | Math | Expected charge |
|---|---|---|---|
| Practice | Surgeon fee | 1 × $5,200 | $5,200.00 |
| Practice | Implants | 2 × $1,250 | $2,500.00 |
| Practice | Post-operative visits | included | $0.00 |
| Surgery center | Facility fee | 1 × $2,400 | $2,400.00 |
| Total | $7,700 + $2,400 | $10,100.00 |
The patient is later billed $2,800 by the surgery center. That is $400 more than the center's $2,400 on the estimate, so the patient can start a dispute for the center's charges. A $2,799 bill would not qualify. If the practice bills $7,900 against its $7,700, that is only $200 over and does not qualify either, even though the overall total is $600 over. The comparison is per provider or facility.
The dispute process and the $400 rule
Under 45 CFR 149.620, a bill is "substantially in excess" when the total billed by a provider or facility is at least $400 more than the total listed for that provider or facility on the estimate. The patient starts the process by notifying HHS, postmarked within 120 calendar days of the first bill, and pays an administrative fee that HHS sets in guidance. The CMS model form shows $25; the fee field in the generator lets you update it.
Your estimate carries the CMS disclaimer wording on these points, including that the provider cannot send a disputed bill to collections or take retaliatory action while the dispute is open. The text of the printed disclaimers follows the CMS model form.
Using this good faith estimate template in your practice
Enter your practice details once; they are saved in your browser, not on a server. Patient details stay in the page and are never saved or put in the URL. Add a co-provider block for each separate facility or group, add your own codes and charges, then print or save as PDF. The tool does not look up or suggest codes. Your coder owns those, and so does the decision on what to quote.
Practices that quote surgery and treatment plans every week usually keep the estimate with the visit record. Prospyr's plastic surgery software and charting keep quotes, consults and consents in one patient chart; this template is a starting point either way.
Frequently asked questions
What is a good faith estimate?
A good faith estimate is a written notification of expected charges for a scheduled or requested item or service, including items reasonably expected to be furnished with it. 45 CFR 149.610(a)(2)(vi) defines it. For an uninsured or self-pay patient, the expected charge is your cash-pay rate, with any discount you offer to those patients.
Who needs a good faith estimate?
An uninsured or self-pay patient does. That is someone with no health coverage for the service, or someone who has coverage but does not want a claim sent to the plan (45 CFR 149.610(a)(2)(xiii)). The convening provider has to ask each patient which applies and tell self-pay patients that an estimate is available.
How long do you have to give a good faith estimate?
Within 1 business day of scheduling when the service is at least 3 business days away, within 3 business days of scheduling when it is at least 10 business days away, and within 3 business days of a patient request. An updated estimate is due no later than 1 business day before the service if the scope or charges change. The deadline helper in the tool counts these dates for you.
What must a good faith estimate include?
The patient's name and date of birth, a plain-language description of the primary service and its date, an itemized list grouped by provider or facility, diagnosis codes, service codes and expected charges, and each provider's name, NPI, tax ID, state and location. It also needs a list of separately scheduled items with a disclaimer above it, plus disclaimers about additional items, estimate-only charges, dispute rights and that it is not a contract.
Is a good faith estimate a contract?
No. The estimate must say that it is not a contract and that the patient is not required to get the items or services from any provider or facility named in it (45 CFR 149.610(c)(1)(xi)). It is also part of the patient's medical record and must be kept like one, and you must give a patient a copy of any estimate issued in the last 6 years if they ask.
When can a patient dispute a bill after a good faith estimate?
When the total billed by a provider or facility is at least $400 more than that provider's or facility's total on the estimate. The patient has to start the dispute postmarked within 120 calendar days of the first bill (45 CFR 149.620). The test is applied to each provider or facility separately, not to the grand total.
Does the good faith estimate rule apply to aesthetic and cosmetic procedures?
The rule is written around any item or service furnished by a licensed provider or facility to a self-pay patient, and it does not name aesthetic care as an exception. Whether a given cash-pay service line is covered is a legal question, so ask your counsel or compliance lead. If you already give patients written price quotes, the CMS model form is a ready structure for them.
Sources and scope
- 45 CFR 149.610: Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals (eCFR)
Definitions, timing, content requirements (c)(1), delivery method and record-keeping. Quoted and summarized in the sections above.
- 45 CFR 149.620: Requirements for the patient-provider dispute resolution process (eCFR)
The $400 "substantially in excess" definition, the 120-day window and the administrative fee set by HHS guidance.
- CMS model notice: Good Faith Estimate for Health Care Items and Services (Appendix 2, PDF)
The standard form and disclaimer language this generator follows. HHS considers use of the model notice good-faith compliance with the content requirements.
- CMS model notice: Right to Receive a Good Faith Estimate (Appendix 1, PDF)
The notice practices post and give patients about the availability of an estimate.
- CMS: Medical bill rights, uninsured or self-pay patients
Plain-language patient view of the estimate and the $400 dispute threshold.
- CMS: Requirements for NPI and NPI check digit (PDF, 2004)
The Luhn check-digit method the tool uses to flag mistyped NPI numbers. A passing number is not proof the NPI is assigned to your practice.
A template, not legal advice. It follows 45 CFR 149.610 and the CMS model form but does not check your codes or charges, and it cannot tell you whether a specific service is covered by the rule. State laws may add requirements. Confirm with your counsel or compliance lead before relying on it.