Good Faith Estimate Form

The Good Faith Estimate Form helps healthcare providers comply with the federal No Surprises Act by providing uninsured and self-pay patients with a written estimate of expected charges before receiving non-emergency care. It captures all the information mandated by the regulation, including patient identifying details, a description of each anticipated service, corresponding billing and diagnosis codes, the expected charge for each line item, and the name and NPI of every provider expected to furnish services as part of the care episode.

The form is structured to accommodate both single-provider estimates and convening-provider scenarios where multiple clinicians contribute to a patient's care. It includes fields for the primary scheduled service, ancillary services such as anesthesia, lab work, pathology, or imaging, and the facility fee if care will take place at a hospital or ambulatory surgery center. A clear total estimated cost line gives the patient a single number to reference, while a disclaimer section explains the patient's right to dispute charges that exceed the estimate by more than four hundred dollars through the federal dispute resolution process.

Essential for every healthcare provider subject to the No Surprises Act, including physician offices, hospitals, ambulatory surgery centers, imaging centers, and laboratories. Compliance teams use it to ensure estimates are delivered within required timeframes, billing departments use it to standardize cost communication, and financial counselors use it to facilitate transparent conversations about expected out-of-pocket expenses.