Good faith estimate template

Who this applies to

Good faith estimates are required for uninsured and self-pay patients — patients who are not using insurance for the service. This is a separate track from the provider-payer IDR process. It has its own timelines, its own $400 threshold, and its own dispute mechanism.

Required elements

Every good faith estimate must contain the following. Omitting any of them is a compliance gap:

• Patient name and date of birth
• Description of the primary item or service, in clear and understandable language
• Itemized list of items and services reasonably expected to be furnished, grouped by provider or facility
• Applicable diagnosis codes, service codes, and expected charges for each item
• Name, NPI, and TIN of each provider or facility represented, and the location where services will be furnished
• Items and services that may be provided by another entity but are not included — listed separately with a note that separate estimates will be issued on request
• Disclaimer that the estimate is only an estimate and actual items or services may differ
• Disclaimer explaining the patient-provider dispute resolution process and the $400 threshold
• Disclaimer that the estimate is not a contract and does not obligate the patient to obtain the services

Copy-ready structure

Use the block below as your document skeleton. Replace the bracketed fields; keep the disclaimer section intact, since the language is what carries the compliance weight.

Header — Good Faith Estimate of Expected Charges · Date issued · Patient name · Patient date of birth

Section 1 — Convening provider — Name · NPI · TIN · Service location · Contact

Section 2 — Primary item or service — Plain-language description · Expected date of service · Diagnosis code(s)

Section 3 — Itemized expected charges — For each line: provider or facility name · service code · description · expected charge. Subtotal by provider. Total expected charges.

Section 4 — Items not included — Services that may be furnished by other providers, with a note that a separate estimate is available on request.

Section 5 — Disclaimers — Estimate-only language · patient-provider dispute resolution and the $400 threshold · not a contract · right to request an estimate for any scheduled or requested service.

Where this goes wrong

The two failures we see most often are missing co-provider line items — the estimate covers the surgeon but not anesthesia or pathology — and boilerplate disclaimers that omit the dispute-resolution explanation entirely. Both are correctable in the template rather than case by case.

This is operational guidance, not legal advice. Requirements are set by federal regulation and can change; confirm current rules before adopting a template practice-wide.