Free Good Faith Estimate template and generator
The No Surprises Act requires therapists, psychologists, dietitians and other practitioners to give self-pay and uninsured patients a Good Faith Estimate of what their care will cost. Fill in the form and download a PDF with everything the rule asks for, disclaimers included.
The PDF is made in your browser. What you type about the patient is never sent to CloudMedico, stored or emailed.
Nothing you type in this form leaves your browser. Reloading the page clears it.
Your practice
Patient
Main service
Recurring sessions
Diagnosis codes (optional)
If you've made a diagnosis and it's needed to work out the estimate. Up to four.
Services and expected charges
Type your own service codes and descriptions.
$0.00
Total expected charges: $0.00
Services scheduled separately (optional)
Care you expect to be scheduled separately, for example with another provider. They get their own estimates.
Notes (optional)
Get a reminder before it runs out
Fill in the dates of the recurring sessions above, and you can ask for a reminder before the estimate runs out.
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What a Good Faith Estimate is
A Good Faith Estimate (GFE) is a written estimate of the charges a patient can expect for the care you've scheduled or they've asked about. Since January 1, 2022, the No Surprises Act requires providers to give one to patients who are uninsured, or who have insurance but don't want you to bill it. The rule is 45 CFR 149.610.
Patients keep it to compare with your bills. If a bill is at least $400 more than the estimate, they can dispute it.
When you have to give one
- Within 1 business day of scheduling, when the service is at least 3 business days away.
- Within 3 business days of scheduling, when the service is at least 10 business days away.
- Within 3 business days of a patient asking for one. Any question about what care will cost counts as asking.
- Again, at least 1 business day before the service, if what you expect to provide or charge changes.
What it must include
- The patient's name and date of birth.
- The main service in plain language, and its date if it's scheduled.
- Each service you expect to provide, with its service code (for example CPT or HCPCS), any diagnosis codes, and the expected charge.
- Your name, NPI and Tax Identification Number, and the state and address where you'll see the patient.
- Services you expect to be scheduled separately, such as with another provider, with a note that they'll get their own estimates.
- Disclaimers: it's only an estimate, other care may be recommended separately, the patient can dispute a bill that is $400 or more over it (and disputing won't affect their care), and it isn't a contract.
Weekly sessions: one estimate for up to 12 months
For recurring care, such as weekly therapy, one estimate can cover the sessions if it says how often they are, how many, and over what dates. It can't cover more than 12 months. After that, or if the plan or your fees change, give the patient a new estimate and tell them what changed.
This generator stops a recurring estimate at 12 months and can remind you by email before it runs out.
Keep a copy
A Good Faith Estimate is part of the patient's medical record. Keep it the way you keep the record, and give the patient a copy of any estimate from the last 6 years if they ask. It must be in writing, on paper or electronically, in a form the patient can save and print: a PDF does that.
About this template
This is a template, not legal advice. It follows 45 CFR 149.610 and the sample estimate published by CMS, as we read them on November 4, 2026. Your state may have rules of its own. You're responsible for what goes into the estimate you give.
Type your own service codes and descriptions. The generator doesn't include any code list.
Questions
Do therapists have to give a Good Faith Estimate?
Yes, to patients who are uninsured or who choose not to use their insurance for your sessions. That includes counselors, psychologists, social workers, marriage and family therapists and other licensed practitioners who see self-pay patients.
My client has insurance but pays me directly. Do they need an estimate?
Yes, if they don't want you to submit a claim to their insurer. The rule counts them as self-pay.
How long is a Good Faith Estimate valid for recurring sessions?
One estimate can cover recurring sessions for up to 12 months. After that, give a new one, and say what changed.
Do I have to put a diagnosis code on it?
The rule asks for the applicable diagnosis codes. CMS's sample estimate asks for them where they're needed to work out the estimate. If you haven't made a diagnosis yet, you can leave them out.
What happens if my bill is higher than the estimate?
If the total you bill is at least $400 more than your estimate, the patient can start a dispute with the U.S. Department of Health and Human Services within 120 calendar days of the bill. The fee to them is $25.
Does CloudMedico see the patient details I type?
No. The PDF is made in your browser and nothing you type about the patient is sent to us. If you ask for a reminder, we keep only your email, the date you made the estimate and the last date it covers.
Sources (read November 4, 2026)
- 45 CFR 149.610: Good Faith Estimates for uninsured (or self-pay) individuals (eCFR)
- CMS: Sample Good Faith Estimate for uninsured (or self-pay) individuals
- 45 CFR 149.620: Patient-provider dispute resolution (eCFR)
- CMS: Sample notice of the right to a Good Faith Estimate
- CMS: Your right to a Good Faith Estimate
- CMS: Dispute a medical bill