What goes in a good faith estimate template, and who must give one?
By Konstantin Kaufmann ·
A good faith estimate lists the client's name and date of birth, the service in plain words, itemized expected charges with service codes, your NPI and tax ID, and four fixed disclaimers, under 45 CFR §149.610(c)1. A covered provider owes one to uninsured or self-pay clients who ask for it or who book at least 3 business days ahead, as of October 14, 20262.
Free good faith estimate generator
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What must a good faith estimate contain?
Section 149.610(c)(1) lists the contents1. The generator above has one field or fixed text for each item:
| Generator field | What the rule requires | Section |
|---|---|---|
| Client name, date of birth | "Patient name and date of birth" | (c)(1)(i)1 |
| Primary service, care period | The primary service "in clear and understandable language", and its date if scheduled | (c)(1)(ii)1 |
| Service lines: description, expected date, location, quantity | An itemized list of services expected for the period of care, grouped by provider | (c)(1)(iii)1 |
| Diagnosis code (optional), service code, unit expected cost | "Applicable diagnosis codes, expected service codes, and expected charges" for each line | (c)(1)(iv)1 |
| Provider name, type, NPI, EIN, address, state; service location on each line | Name, National Provider Identifier and Tax Identification Number, plus the state and office location where the services are expected | (c)(1)(v)1 |
| Services that need separate scheduling | A list of those services, with a disclaimer directly above it. Codes and charges for them are not needed | (c)(1)(vi)1 |
| Fixed notices | Four disclaimers: other recommended services are not reflected; this is only an estimate; the client can start a bill dispute; the estimate is not a contract | (c)(1)(viii) to (xi)1 |
The dispute disclaimer must say where to find instructions. It must also say that a dispute "will not adversely affect the quality of health care services"1. The generator prints the four disclaimers as three fixed paragraphs, plus a separate-scheduling note. The first paragraph joins the "other services" and "only an estimate" disclaimers. The dispute paragraph names the CMS help desk, 1-800-985-30592.
The diagnosis code field is optional because the rule asks only for "applicable" codes1. The generator also makes the NPI field optional, but the rule lists the NPI1. We found no CMS text on providers who have no NPI. If you have none, ask CMS before you rely on "Not assigned".
You give the estimate in writing, on paper or electronically, as the client asks. An electronic copy must be one the client "can both save and print"1. A PDF file can be saved and printed. That is our reading, not CMS text.
When is a good faith estimate due, and how fast?
The deadline depends on how far ahead the client books1, 2:
| The client... | Estimate due | Section |
|---|---|---|
| books 3 to 9 business days ahead | within 1 business day of booking | §149.610(b)(1)(vi)(A) ("at least 3"), CMS split1, 2 |
| books 10 or more business days ahead | within 3 business days of booking | §149.610(b)(1)(vi)(B)1, 2 |
| asks for an estimate | within 3 business days of the request | §149.610(b)(1)(vi)(C)1 |
| books 0 to 2 business days ahead | CMS says the client is "not entitled" to an estimate for that booking | CMS consumer guide2 |
The rule treats "any discussion or inquiry regarding the potential costs" of services under consideration as a request1. So a client who asks "what will this cost me?" has made a request. The CMS guide says a request is answered within 3 business days2.
For ongoing weekly sessions, one estimate can cover the series. It must state the frequency and the total number of sessions, and it can cover at most 12 months1. After 12 months, issue a new one.
If you expect a change in scope, such as different expected charges, frequency or duration, issue a new estimate. It is due no later than 1 business day before the service1.
Who must give a good faith estimate?
The rule applies to a "health care provider" acting "within the scope of practice of that provider's license or certification under applicable State law"1. The requirements apply to estimates requested, and to services scheduled, on or after January 1, 20221.
The client must be uninsured or self-pay. Self-pay includes a client with a group health plan or insurance who does not want a claim filed with it1. CMS adds one limit: people enrolled in a federal health care program, such as Medicaid or Medicare, are not eligible for an estimate, even if they do not plan to use that coverage3.
You must also tell clients that estimates exist. Put the notice where clients see it: on your website, in your office and where scheduling or cost questions occur. Also say it aloud when you schedule a service or when cost questions occur1.
The estimate is part of the client's medical record. Keep it the same way. A client can ask for a copy of any estimate issued in the last 6 years1.
Does a somatic practitioner with only a training certificate need one?
Unknown. The definition turns on a license or certification "under applicable State law"1. We found no primary source that says whether a private training certificate counts.
What is known:
- If you hold a state license and act within its scope of practice, the license condition of the definition is met1.
- If your only credential is a certificate from a training school, the federal text does not answer the question1.
Our reading, not a legal finding: calling a session "coaching" does not settle it. The state's view of your service and credential decides.
Ask your state licensing board two questions in writing:
- Does the state license or certify the service I offer, as I describe it to clients?
- Does my training certificate count as a state certification?
State pages: California, Colorado, New York, Oregon, Washington.
What does a filled good faith estimate look like?
Here is a fictional example. Download the example PDF above for the full layout.
| Field | Example entry |
|---|---|
| Client | Sam Rivera, born 04/12/1988 |
| Primary service | Weekly individual counseling sessions, 50 minutes |
| Care period | 11/02/2026 to 01/18/2027, weekly, 12 sessions1 |
| Provider | Jordan Lee, Licensed Professional Counselor, Portland, Oregon; NPI and EIN listed |
| Service line | Individual session, service code 90834, quantity 12, unit expected cost $140 |
| Total expected charges | $1,680 |
| Separate scheduling | No separately scheduled services currently anticipated |
| Fixed notices | The four disclaimers1 |
The total is quantity times unit cost: 12 × $140 = $1,680. The last section shows why this total matters.
Do I have to use the CMS form?
No. CMS says providers "do not have to use this specific form, as long as they use a form that includes the required information"4. The generator follows the §149.610(c) list instead of the CMS layout. It runs in your browser: OneSomatic does not receive what you type.
The rule also covers co-providers, such as a second practitioner in the same course of care. In its December 2, 2022 FAQ, HHS extended enforcement discretion for estimates that omit co-provider charges, "pending future rulemaking"5. CMS repeated this in a document dated April 23, 20246. We found no later notice that ended it. Check again before you rely on it.
What happens if the bill is $400 more than the estimate?
The client may start the federal patient-provider dispute resolution process. A bill qualifies if your total billed charges are at least $400 more than the total expected charges on the estimate7, 8. The total billed charges include services that were not on the estimate7. The client must send the initiation notice within 120 calendar days of receiving the initial bill, by postmark, and pay an administrative fee7. We did not check the fee amount.
To avoid a dispute, keep the total realistic. Issue a new estimate when the plan changes1.
This page is information, not legal advice. Rules checked October 14, 2026.
Sources
- eCFR, 45 CFR §149.610(a)(2)(viii). Checked .
- CMS, "Good faith estimate" consumer guide. Checked .
- CMS, "Decision Tree: Requirements for Good Faith Estimates for Uninsured (or Self-Pay) Individuals" (revision date 9/2023), step 1b. Checked .
- CMS, "Sample Good Faith Estimate for Uninsured (or Self-Pay) Individuals". Checked .
- CMS, "FAQs about Consolidated Appropriations Act, 2021 implementation, Good Faith Estimates for uninsured (or self-pay) individuals, Part 3" (Dec 2, 2022), Q1. Checked .
- CMS, "Progress Toward Advanced Explanation of Benefits (AEOB) Rulemaking and Implementation" (April 23, 2024), footnote 2. Checked .
- eCFR, 45 CFR §149.620(a)(2)(ii). Checked .
- CMS, "Medical bill disagreements if you are uninsured". Checked .