Good Faith Estimate Template No Surprises Act: FAQ & Example

The No Surprises Act requires you to give a good faith estimate to uninsured and self-pay patients. Learn more about the good faith estimate template and some of the more frequently asked questions surrounding good faith estimates.

Just want to download a good faith estimate template? Fill out the form below and we'll send you our editable template that satisfies all the CMS requirements outlined in this article.

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Good faith estimate template example

The following is an example of a good faith estimate template. The Centers for Medicare and Medicaid Services (CMS) have created a good faith estimate template that is No Surprises Act compliant. You can use this template in your practice. We have included a detailed explanation of each page to clarify the components and point out essential elements that you may otherwise overlook.

The CMS example good faith estimate form consists of five total pages. Four pages are forms to be completed. The final page is a disclaimer.

Patient information and diagnosis page

The first page is the patient information and diagnosis page. This page is relatively straightforward, but accuracy is vital. Be careful to double check for errors and omissions. Any patient information errors can delay a potential patient-provider dispute process involving a third party.

It is important to remember that the good faith estimate is considered part of your patient's medical record. Therefore, you should always follow all applicable regulations like HIPAA.

Starting from the top of the first page of the good faith estimate template, you should complete the following:

1. The name of the provider or your facility.

2. The patient's information, including first name, middle name, last name, date of birth, and patient identification number.

3. The patient's mailing address, phone number, email address, and contact preference*

4. The patient's diagnosis, including:

• The patient's primary service or item requested or scheduled.
• The patient's primary diagnosis, along with the primary diagnosis code.
• The patient's secondary diagnosis, along with the secondary diagnosis code.

* The patient contact preference notes whether the patient prefers you to contact them via mail or email.

List of expected charges page

The second page is the list of expected charges page. Your biggest concern here should be the estimated total costs. Ensure the estimated total costs match what is shown on the itemized estimates on the following pages. You should also ensure the total estimated cost aligns with the total estimated cost provided after all the itemized estimate pages.

You may need to make slight changes to the template depending on how many providers you must list:

• One provider: If only one provider exists, you can leave the other provider fields bank or omit them from the form.
• Multiple providers: If there are multiple providers, you should list them all.
• More than three providers: If there are more than three providers, you can add new lines to the template to accommodate the additional providers.

Starting from the top of the second page of the good faith estimate template, you should complete the following:

1. Enter the dates the primary service or item will be provided.

• Check the box if the dates for the service or item still need to be scheduled.

2. Enter the date of the good faith estimate.

3. List each provider and their estimated total costs.

4. Add each provider's estimated total costs to find the total estimated cost and enter it on the form.

5. Below the total estimated cost, customize the fine print:

6. First, list the primary service or item referred to on this page.

7. Next, list the date of service, if scheduled. Note here whether the item or services are recurring.

8. Include the following information: "The estimated costs are valid for 12 months from the date of the Good Faith Estimate."

9. Remember to delete any excess brackets and instructions before you deliver the good faith estimate to the patient.

Itemized estimate from provider page

The next page is the itemized estimate from the provider page. With this page, your main concern should be accuracy. You should be careful to ensure accuracy with the following:

• Service items
• Diagnosis codes
• Service codes
• Expected costs

Remember, if the patient's final bill costs at least $400 more than the estimate, they can initiate the patient-provider dispute process (PPDR).

Starting from the top of the itemized estimate from provider page, you should complete the following:

1. The provider or facility name and type.

2. The provider or facility's mailing address.

3. The provider or facility's contact person, along with their phone number, email, national provider identifier, and their taxpayer identification number.

4. The details of services and items provided by the first provider, including the following information for each service or item:*

• The service or item name.
• The address where the service or item will be provided, including the street, city, state, and zip code.
• The diagnosis code.
• The quantity.
• The expected cost.

5. The total expected charges from the first provider or facility — this number should accurately reflect the sum of the estimated cost of each item or service to be rendered by this provider or facility.

6. Additional health care provider or facility notes.

* There are three rows provided for services and items. If there are more than three services, you may add more lines.

Itemized estimate from additional provider page

The final form page is the itemized estimate from additional providers page. This is where you should include the estimates from additional providers or facilities. This page is filled out almost exactly like the previous page, the itemized estimate from the provider page. However, at the bottom of the page, there is a section where you should include the total estimated cost for all services and items.

Starting from the top of the itemized estimate from additional provider page, you should complete the following:

1. The provider or facility's name, followed by the word "Estimate".

2. The additional provider or facility name and type.

3. The additional provider or facility's mailing address.

4. The additional provider or facility's contact person, along with their phone number, email, national provider identifier, and taxpayer identification number.

5. The details of services and items provided by this provider, including the following information for each service or item*:

• The service or item name.
• The address where the service or item will be provided, including the street, city, state, and zip code.
• The diagnosis code.
• The quantity.
• The expected cost.

6. The total expected charges from the additional provider or facility. This number should accurately reflect the sum of the estimated cost of each item or service to be rendered by this provider or facility.

7. If you have additional health care provider or facility notes that you would like to include, you may do so at the designated area at the bottom of this page.

8. Enter the total estimated cost for all services and items from the listed providers and facilities. This number must match the "total estimated cost" on the previous "list of expected charges page."

Notes:

• If there is more than one additional provider or facility, add additional pages.
• The convening provider is the provider who delivers the estimate to the patient, but the co-providers must still provide cost estimates.
• If there is only one provider, you will list the total of their estimated costs in the "Total estimated cost for all services and items."

Disclaimer page

The final page in the good faith estimate template is the disclaimer page. You can change some of the wording for this disclaimer if you prefer. However, there are several disclaimer requirements. For this reason, we recommend keeping it simple and using this disclaimer as provided by the CMS.

Good faith estimate disclaimer requirements

Four disclaimer requirements must be adhered to. You must ensure you meet these requirements if you choose to alter the disclaimer. These requirements are:

1. The disclaimer must inform the self-paying patient that additional services or items may be recommended as part of the patient's care. These services and items must be requested or scheduled separately and are not reflected in this good faith estimate (GFE).
2. The disclaimer must inform the self-paying patient that the information provided in the GFE is only an estimate of the services or items reasonably expected to be furnished when the GFE is issued to the patient. The actual services, items, or charges may differ from those in the GFE.
3. The disclaimer must inform the self-paying patient of their right to initiate the PPDR process if their billed charges are substantially higher than those charges estimated in the GFE. The disclaimer must also include instructions for finding more information about initiating the PPDR process. The disclaimer must state that the initiation of the PPDR process won't adversely affect the quality of the health care services they will receive.
4. The disclaimer must inform the self-paying patient that the GFE is not a contract and doesn't require the patient to accept the listed services or items from the providers or facilities listed.

Good faith estimate template FAQ

The following are answers to some of the most frequently asked questions about the good faith estimate template.

Do you have to use the good faith estimate template exactly as provided by the CMS?

No, you are free to make some changes and modifications. You can even design your own template, but you must always adhere to the CMS's good faith estimate content requirements.

Who has to receive the good faith estimate form under the No Surprises Act?

Under the No Surprises Act, you must supply the good faith estimate form to all uninsured and self-pay individuals.

How should the good faith estimate be provided?

You must provide the good faith estimate in a written format. It can be in either paper or electronic format, depending on the patient's preferences.

When should the good faith estimate notice be provided?

You should provide the good faith estimate within one business day after receiving the request or scheduling the appointment.

However, here is the maximum time you have to provide a GFE under various circumstances:

• When a primary service or item is scheduled at least three business days early, you must provide the GFE within one business day of the date of scheduling.
• When a primary service or item is scheduled at least 10 business days in advance, you must provide the GFE within three business days of scheduling the appointment.
• When a self-paying patient requests a GFE, you must provide the GFE within three business days of the request.

Do I have to provide a good faith estimate every time for a recurring service?

You are allowed to issue a single GFE for a recurring primary service or item if you meet the following requirements:

• The GFE includes the expected scope of the recurring primary service or item clearly and understandably. The expected scope may include frequency, timeframes, and the total number of recurring services or items.
• The scope of the GFE for recurring primary services or items must not exceed 12 months.

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MD Clarity's Clarity Flow software makes it easy to build and deliver accurate good faith estimates that comply with the No Surprises Act. It can integrate with your EHR system and auto-send estimates via email, text, or letter. Patients can also pay directly from their estimate.

Book a demo to see how MD Clarity can boost your patient experience and your bottom line at the same time with automated good faith estimates.