Good Faith Estimate Generator
Create a No Surprises Act-compliant Good Faith Estimate in minutes. Enter your practice details, add services with CPT codes, and generate a properly formatted GFE — ready to print or share with patients.
Pre-filled with a realistic mental health practice example. Edit any field below — the estimate updates in real time.
Provider / Facility Information
Patient Information
Estimate & Service Dates
Services & Expected Charges
Good Faith Estimate
Pursuant to the No Surprises Act — 45 CFR § 149.610
Summit Behavioral Health
2100 Market Street, Suite 400, Philadelphia, PA 19103
(215) 555-0173NPI: 1234567890EIN: 84-1234567
Specialty: Psychology / Mental Health
Patient Information
Patient Name: Sarah K. Chen
Date of Birth: July 22, 1992
Address: 315 Pine Street, Apt 4B, Philadelphia, PA 19106
Phone: (215) 555-0284
Estimate Details
Estimate Date: March 9, 2026
Expected Service Date: March 16, 2026
Estimate Valid Until: March 9, 2027
Service Location: 2100 Market Street, Suite 400, Philadelphia, PA 19103
Itemized Services & Expected Charges
| CPT/HCPCS | Description | Dx Code | Qty | Unit Cost | Total |
|---|---|---|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | F41.1 | 1 | $275.00 | $275.00 |
| 90837 | Psychotherapy, 60 minutes | F41.1 | 12 | $225.00 | $2,700.00 |
| 96127 | Brief emotional/behavioral assessment | F41.1 | 4 | $15.00 | $60.00 |
| Estimated Total Charges: | $3,035.00 | ||||
Required Disclaimers
- This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for the item or service listed above. The estimate is based on information known at the time the estimate was created.
- The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.
- This is not a contract or guarantee of costs. Actual charges may differ from this estimate. You have the right to receive an updated estimate if the scope of services changes.
Your Rights Under the No Surprises Act
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill through the patient-provider dispute resolution process.
- You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate.
- You can contact HHS at 1-800-985-3059 or visit www.cms.gov/nosurprises for questions or more information about your right to a Good Faith Estimate.
Acknowledgment
I have received and reviewed this Good Faith Estimate. I understand that actual charges may vary from the estimates provided above.
Patient Signature (or Authorized Representative)
Date
What Is a Good Faith Estimate?
A Good Faith Estimate (GFE) is a written document that itemizes the expected costs of healthcare services for uninsured or self-pay patients. Required under the No Surprises Act (effective January 1, 2022), the GFE gives patients price transparency before they receive care — and legal recourse if the final bill significantly exceeds the estimate.
The regulatory requirements are codified at 45 CFR § 149.610. Every state-licensed or certified healthcare provider and facility must comply, including physicians, therapists, dentists, chiropractors, and labs. Unlike the HIPAA authorization process, which protects patient privacy, the GFE protects patients from unexpected financial burden.
When Is a Good Faith Estimate Required?
Uninsured patients
Any patient who does not have health insurance coverage for the items or services being scheduled.
Self-pay patients
Insured patients who choose not to submit a claim to their insurance and will pay out of pocket.
Upon patient request
Any uninsured or self-pay individual may request a GFE at any time — even before scheduling.
The GFE requirement applies to all non-emergency services. Providers must also post a notice about GFE availability in their office and on their website. For practices that serve both insured and self-pay patients, tracking compliance requirements alongside GFE obligations is essential.
GFE Timing Requirements
The No Surprises Act specifies strict deadlines for providing the estimate based on when the service is scheduled:
| Scheduling Scenario | GFE Deadline |
|---|---|
| Service scheduled 10+ business days in advance | Within 3 business days of scheduling |
| Service scheduled 3-9 business days in advance | Within 1 business day of scheduling |
| Service scheduled < 3 business days in advance | No later than the date of service (best practice: provide at time of scheduling) |
| Patient requests a GFE (no service scheduled) | Within 3 business days of the request |
Practical tip: Build GFE generation into your scheduling workflow. Many practices provide the estimate at the time of scheduling, regardless of lead time, to avoid missed deadlines. Include a copy in your patient intake packet.
How to Use This Good Faith Estimate Generator
- 1
Enter your practice information — Provider name, NPI, EIN, address, and specialty. This identifies the convening or co-provider on the estimate.
- 2
Add patient details — Name, date of birth, address, and phone number. Required for proper identification on the GFE.
- 3
Set estimate and service dates — The date the estimate is prepared, expected service date, and when the estimate expires.
- 4
Add service lines with CPT codes — Enter each expected service with its CPT/HCPCS code, diagnosis code, quantity, and expected charge. Use the quick-select dropdown for common codes.
- 5
Print or copy the estimate — The formatted GFE appears below the builder. Print it, provide it to the patient in paper or electronic form, and retain a copy in your records.
Important: This tool generates a template for informational purposes. Always verify your charges against your current fee schedule. For legal review of your GFE process, consult with a healthcare attorney.
Required GFE Data Elements
CMS specifies the data elements every Good Faith Estimate must include. Missing any element exposes your practice to enforcement risk. This generator includes all of them automatically.
| Element | Regulation |
|---|---|
| Provider name & NPI | 45 CFR § 149.610(c)(1) |
| Provider Tax ID (EIN) | 45 CFR § 149.610(c)(2) |
| Patient name & DOB | 45 CFR § 149.610(c)(3) |
| Service description & codes | 45 CFR § 149.610(c)(4) |
| Diagnosis codes (if applicable) | 45 CFR § 149.610(c)(5) |
| Expected charges per item | 45 CFR § 149.610(c)(6) |
| Service location | 45 CFR § 149.610(c)(7) |
| Disclaimer language | 45 CFR § 149.610(c)(8) |
| Dispute rights notice | 45 CFR § 149.610(c)(9) |
Service codes must use CPT, HCPCS, DRG, or NDC codes. Credentialed providers should use their enrolled NPI number to ensure consistency across documents.
The $400 Dispute Rule
One of the most important patient rights under the No Surprises Act: if a patient's final bill exceeds the Good Faith Estimate by $400 or more, they can initiate the patient-provider dispute resolution (PPDR) process.
Receive a bill at least $400 higher than the GFE
Contact the provider within 120 calendar days of the bill
File a dispute through the HHS patient-provider dispute resolution portal
An independent reviewer determines the appropriate payment amount
The decision is binding on the provider (not the patient)
Provider risk: If the dispute ruling favors the patient, the provider must accept the lower amount. Accurate GFEs are not just a compliance obligation — they're financial protection for your practice. Track your estimates alongside your risk assessment process.
Good Faith Estimates for Mental Health Providers
Mental health providers — therapists, psychologists, psychiatrists, and counselors — were among the most affected by GFE requirements because many of their patients pay out of pocket. The nature of therapy (ongoing, variable duration) makes cost estimation particularly challenging.
Recurring Sessions
Estimate the number of sessions expected over the next 12 months. For weekly therapy, a common estimate is 48-52 sessions at your per-session rate.
Variable Session Length
List each session type separately (45-minute vs. 60-minute, individual vs. family) with distinct CPT codes and charges.
Assessment Sessions
Include diagnostic evaluations (CPT 90791) and psychological testing separately from treatment sessions.
Update Obligations
If treatment plans change (e.g., adding EMDR or group therapy), provide an updated GFE. Keep copies with your informed consent documentation.
For more on documentation requirements specific to behavioral health settings, see our guide on the HIPAA minimum necessary rule and how it applies to mental health records. Practices using the Notice of Privacy Practices should reference GFE availability in their patient-facing documents.
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