formisoft

Good Faith Estimate Form

Asks about patient address, scheduled service date, and primary service description. Built for physician offices providing cost estimates to uninsured or self-pay patients.

Questions
13
Pages
2
Time
about 3 min

Includes

  • Consent agreement
  • Card payment
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Your practice

Good Faith Estimate Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • 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

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What's inside

Before you publish: Review amounts, payment terms, and authorization wording for your practice before sharing.

Page 1 · Your information

  1. Patient NameText · Required
  2. Date of BirthDate
  3. Patient AddressText
  4. Scheduled Service DateDate
  5. Primary Service DescriptionLong Text

Page 2 · Additional details

  1. Estimated Charge per ServiceNumber
  2. Ancillary Services and ChargesLong Text
  3. Facility Fee EstimateNumber
  4. Deposit PaymentPayment
  5. Provider Name and NPIText

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Good Faith Estimate Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 13 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Good Faith Estimate Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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