Good Faith Estimate Form
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Good Faith Estimate Form
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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.
What's included
- Patient identification and contact information fields
- Itemized service descriptions with ICD-10 and CPT/HCPCS codes
- Per-service and ancillary charge estimation fields
- Optional deposit payment collection via Stripe
- Provider name and NPI documentation
- Estimate acknowledgment consent agreement with e-signature
Who uses this template
- Physician offices providing cost estimates to uninsured or self-pay patients
- Ambulatory surgery centers complying with No Surprises Act requirements
- Hospital billing departments standardizing pre-service cost communication
- Patient financial counselors facilitating transparent pricing conversations
All form fields
13 fields across 2 pages. Customize any field after signing up.
How to use the Good Faith Estimate Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Good Faith Estimate Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Good Faith Estimate Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 13 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Good Faith Estimate Form HIPAA compliant?
Yes. All Formisoft templates, including the Good Faith Estimate Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 13 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Good Faith Estimate Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Good Faith Estimate Form for your practice. Set up in minutes.
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