Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Good Faith Estimate Form
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Patient Address
Scheduled Service Date
____ / ____ / ________
Primary Service Description
Diagnosis Code (ICD-10)
Service Billing Codes (CPT/HCPCS)
Additional details
Estimated Charge per Service
Ancillary Services and Charges
Facility Fee Estimate
Provider Name and NPI
Estimate Acknowledgment
Your practice's consent wording goes here.
Signature
Date
Good Faith Estimate Form template from formisoft.com. formisoft.com/intake-templates/good-faith-estimate