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Good Faith Estimate builder

Uninsured and self-pay patients have a right to a written estimate before scheduled care. Fill this in and print it: it includes every element the No Surprises Act rules (45 CFR 149.610) require, and tells you the date it’s due. Nothing you type leaves this computer.

Providers and facilities

List your practice first, then any co-provider or facility in this estimate. Saved on this computer only.

Your practice

Patient and care

Give it to the patient by Wednesday, November 18. When a patient asks for an estimate without scheduling, give it within 3 business days.

Items and services

Item 1

Nothing you enter is sent anywhere. Patient details are cleared when you leave the page.

Still needed: patient name, date of birth, primary service, provider name, a description and service code on every line.

Good Faith Estimate for Health Care Items and Services

Issued November 14, 2026

Patient: ________________

Date of birth: __________

Primary service: ________________

Providers and facilities

NameNPITINLocation

Provider

Item or serviceService codeDiagnosis codeQtyEstimated charge
1$0.00
Subtotal$0.00

Total estimated charges: $0.00

Disclaimers

There may be other items or services your provider recommends as part of your care that must be scheduled or requested separately and are not included 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 it was created. It 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, federal law allows you to dispute (appeal) the bill.

If you are billed at least $400 more than this Good Faith Estimate by any one provider or facility, you have the right to dispute the bill. You may contact that provider or facility to ask them to update the bill to match this estimate, to negotiate the bill, or to ask about financial assistance. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days (about 4 months) of the date on the original bill. There is a small fee to use the process, and an independent reviewer decides what you owe. Starting a dispute won’t affect the quality of care you receive.

This Good Faith Estimate is not a contract. It does not require you to get the items or services from any of the providers or facilities listed.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.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. You may need it if you are billed a higher amount.

A template, not legal advice. Your charges and codes are your own; check them before you give the estimate; keep a copy with the patient’s record. Ask patients whether they have insurance they plan to use: this form is for uninsured and self-pay patients. CMS No Surprises Act guidance.

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