Good Faith Estimate Builder
Uninsured and self-pay patients have a federal right to know expected charges before care. Itemize the services, total them, and print a compliant estimate sheet in under a minute.
Since January 1, 2022, the federal No Surprises Act has given uninsured and self-pay patients the right to a Good Faith Estimate (GFE) of expected charges before they receive care. This builder itemizes the services you expect to provide, totals the expected charges, and produces a clean, print-friendly estimate sheet you can hand to the patient or save to the chart.
Build the estimate
What a compliant Good Faith Estimate must include
- Patient and provider details — the patient’s name and date of birth, the provider’s (or facility’s) name, and the date the estimate is issued.
- An itemized list of the items and services reasonably expected, with service codes (CPT/HCPCS) where available and the expected charge for each.
- A total of the expected charges for the scheduled service — and a clear statement that separate estimates may come from co-providers such as labs or imaging centers.
- The required disclosures — that the estimate is not a bill, that actual charges may differ, and that the patient can dispute a bill that comes in at least $400 over the estimate.
Two process points trip practices up most often. First, timing: the estimate is due before care is provided, on the federal schedule described on the sheet above — building the GFE into scheduling, not billing, is what keeps a practice compliant. Second, co-providers: if you know another provider (anesthesia, an outside lab, a reading radiologist) will be part of the episode, their charges belong on your estimate as a co-provider line or on their own coordinated estimate. Estimates that ignore them are the ones that end in disputes. Our eligibility verification workflow flags self-pay patients at scheduling so the GFE goes out on time, every time.
Frequently asked questions
Who has to receive a Good Faith Estimate?
Any patient who is uninsured, or who is insured but chooses not to use their coverage (self-pay) for the service. The right comes from the No Surprises Act provisions that took effect January 1, 2022, and it applies to scheduled care as well as to estimates requested before scheduling.
Is the Good Faith Estimate a guaranteed price?
No. It is a good-faith estimate of expected charges based on what is known at the time. Actual charges can be higher or lower — but if the final bill from a named provider is at least $400 more than the estimate, the patient can dispute it through the federal patient–provider dispute resolution process.
How long do we have to provide the estimate?
Under the federal timing rules, when care is scheduled at least 10 business days ahead the estimate is due within 3 business days of scheduling; when it is scheduled 3–9 business days ahead, within 1 business day; and when a patient simply asks for one, within 3 business days of the request. This builder creates the document — your scheduling workflow has to deliver it on that clock.
Disclaimer: This tool is provided for educational and planning purposes only. It is not billing, coding, legal, or financial advice, and it does not replace the rules of any specific payer. Requirements and figures change over time — always verify against current CMS guidance and your own payer contracts before acting on a result.