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Good faith estimate generator
Under the No Surprises Act, a good faith estimate is generally required in certain circumstances for uninsured and self pay individuals, including when someone asks for one and when care is scheduled far enough ahead. Fill this in and print it. Everything runs in your browser, and nothing you type leaves this page or gets saved.
Free means free: no account, no card, no fee now or later, and nothing to unsubscribe from. There is no paid version of this tool.
A printed estimate from this tool is a starting point, not proof of compliance. Confirm it carries everything your situation requires before you give it to a patient.
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 | ||||
Your right to a good faith estimate. If you do not have health insurance, or are not using insurance to pay for your care, federal law generally gives you the right to receive a good faith estimate of expected charges when you request one, or when qualifying care is scheduled in advance. If a final bill from a provider is at least $400 more than that provider's good faith estimate, you may be eligible to use the federal patient provider dispute resolution process. For current information about your rights, visit cms.gov/medical-bill-rights.
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. There is a deadline for starting it, counted from the date on your bill, and an administrative fee may apply. Both are set by the government and both have changed, so check the current figures at cms.gov/nosurprises rather than relying on a number printed here. If the reviewer agrees with you, you will pay the price on this estimate.
To learn more and get a form to start the process, go to 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. The good faith estimate tool terms say what the tool does and does not do.
When an estimate is actually required
Worth being precise about, because the shorthand you hear most often is wider than the rule. It is not that every self pay patient gets an estimate. Under current federal guidance an uninsured or self pay individual is generally entitled to one when they ask for one, or when qualifying care is scheduled far enough ahead, and the timing depends on how far ahead.
A self pay individual here means somebody without coverage for the service, or somebody with coverage who does not intend to have a claim submitted for it.
- Care scheduled 0 to 2 business days out: the federal requirement generally does not call for an estimate before the visit.
- Care scheduled 3 to 9 business days out: generally within 1 business day of scheduling.
- Care scheduled 10 or more business days out: generally within 3 business days of scheduling.
- A request made before anything is scheduled: generally within 3 business days of the request.
Emergency care is handled by other parts of the No Surprises Act, not by the estimate requirement. Your state may add requirements of its own on top of all of this.
Providers and facilities also generally have to make notice of the right to an estimate available to uninsured and self pay patients, and CMS says that notice should be clearly displayed where it applies and easy to find on your website.
Those timing figures are current as of when this page was last updated. CMS publishes the requirements at cms.gov/nosurprises and the patient facing version at cms.gov/medical-bill-rights. Rules change, so check there rather than trusting a template you found last year, including this one.
Also free, elsewhere on the network
The paperwork around this one
An estimate rarely arrives alone. shrinkiatry publishes a Good Faith Estimate explainer covering what the No Surprises Act requires and how the dispute process works, plus an example financial and payment policy and a superbill and CMS-1500 explainer for out of network patients.