# Good Faith Estimate Rules and Template for Private Practices

> Good faith estimate rules for private-pay practices: who counts as self-pay, when it's due, what it must include, the website notice, and a template.

*Source: https://fillthelobby.com/blog/good-faith-estimate*

## Good faith estimates for private-pay practices: the rules, and a template

Under the No Surprises Act, uninsured and self-pay patients are generally entitled to a written good faith estimate of expected charges when they book at least 3 business days ahead or ask about cost. In a cash-pay practice that is most patients. It has to be itemized, and your website has to say estimates are available. Fill The Lobby builds that notice into every pricing and booking page.

By [Ghazanfar Idrees](https://fillthelobby.com/about#ghazanfar-idrees), Co-founder & COO · Updated 28 September 2026 · 6 min read

A good faith estimate is a written, itemized estimate of what a patient can expect to pay, which federal No Surprises Act rules require for uninsured and self-pay patients. Most guides to it are written for patients. This one is for the practice that has to produce it, especially a cash-pay or private-pay practice, where almost every patient is self-pay.

It covers who is entitled to one, when it's due, what it has to include, what your website has to say, and a template to adapt. It is a summary of federal rules, not legal advice.

## Who is entitled to a good faith estimate

The rules at [45 CFR 149.610](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610) cover uninsured and self-pay individuals. Self-pay means two groups, and the second one matters most in a private practice:

- anyone without coverage for the service, and
- anyone who has coverage but chooses not to have a claim submitted, including patients who pay you directly and plan to seek out-of-network reimbursement themselves with a [superbill](https://fillthelobby.com/blog/what-is-a-superbill). Treat them as entitled unless your attorney says otherwise.

## When a good faith estimate is due

Here is what [CMS's guide to good faith estimates](https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/medical-bill-guides-resources/what-good-faith-health-insurance-estimate) and the regulation say (checked 15 September 2026):

| Situation | Estimate due |
| --- | --- |
| Self-pay patient books 3 to 9 business days ahead | Within 1 business day of booking |
| Self-pay patient books 10 or more business days ahead | Within 3 business days of booking |
| Patient asks about cost | Within 3 business days of the request |

The regulation treats any discussion or inquiry about the potential cost of a service as a request for an estimate. A price question on a free consultation call counts.

## Recurring care: one estimate for up to 12 months

For therapy, psychiatry follow-ups, memberships and programs, the regulation at [45 CFR 149.610(b)(1)(x)](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610) allows one estimate for recurring services, provided it sets out the expected scope, such as timeframes, frequency and total number of visits, and covers no more than 12 months. If the plan of care changes, issue a new one.

## What a good faith estimate includes

The estimate is written, on paper or electronically, itemized, and kept with the patient's record. The regulation sets out what it has to contain; in summary:

- the patient's name and date of birth;
- a plain-language description of the main service, with its scheduled date if there is one;
- an itemized list of the services expected, with service codes, diagnosis codes where applicable, and the expected charge for each;
- the name, NPI and tax ID of each provider, and where the services will be delivered;
- services that will need to be scheduled separately;
- standard statements that it is an estimate and not a contract, that actual charges may differ, and that the patient can dispute a bill substantially above the estimate.

Read the regulation itself, or use a model form, before you finalize yours, and have a healthcare attorney check it.

## Good faith estimate template

A layout for a private-pay practice with recurring sessions. Replace everything in brackets.

Good faith estimate

[Practice name] · [Address] · Tax ID: [EIN] Provider: [Name, credentials] · NPI: [number] · Location: [office address, or telehealth from state]

Patient: [Name] · Date of birth: [date] · Estimate issued: [date]

Service: [Plain-language description, e.g. "individual psychotherapy, weekly"] · First scheduled date: [date]

Expected services, [start date] to [end date, no more than 12 months]: [Service] · Code: [CPT] · Diagnosis code: [if applicable] · [$ per visit] × [expected number] = [$] [One line per service]

Total estimated charges: [$]

Services that may be scheduled separately and are not included: [list, or "none expected"]

This is an estimate, not a contract, and does not require you to obtain the services from us. Actual charges may differ. If you are billed at least $400 more than this estimate, you can dispute the bill through the federal patient-provider dispute resolution process. Keep a copy of this estimate.

## What your website has to say

Part of the rule reaches your website. Under 45 CFR 149.610(b)(1)(iii), the availability of good faith estimates has to be written clearly and prominently displayed on your website, in the office and wherever scheduling or cost questions happen, easily searchable from a public search engine, given out loud when someone schedules or asks about cost, and available in accessible formats and the languages of the people scheduling with you.

CMS publishes a [sample notice of the right to a good faith estimate](https://www.cms.gov/files/document/nsa-gfe-required-notice.pdf) to use as a model. Put it as text, not an image, on your fees page and your booking page. Our guide to [showing prices on your website](https://fillthelobby.com/blog/functional-medicine-pricing) covers how the notice sits next to a price list.

A pricing page is not a good faith estimate. The page is a public price list; the estimate is a written document for one patient. The rules require the estimate and the notice. The price list is your choice, and one doesn't replace the other.

## Disputes: the $400 line

A patient billed at least $400 more than a provider's estimate can use the [federal patient-provider dispute process](https://www.cms.gov/initiatives/no-surprise-billing/overview/policies-resources/providers-payment-resolution-patients) to [dispute the bill](https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/dispute-medical-bill) if it is dated within the last 120 calendar days. The practical protection is an honest estimate: include everything you expect to charge, and issue a new estimate when the plan changes.

## Make it part of booking, not an afterthought

The practices that get this right build it into the path a new patient already takes:

1. The fees page and the booking page carry the notice as text.
2. Booking triggers the estimate, so the timing rules are met without anyone remembering.
3. The first-call script treats any cost question as a request and says an estimate will follow.
4. A new estimate goes out whenever the plan of care changes.

Done this way it is also good marketing: a patient who sees the price, the notice and a clear estimate has fewer reasons to hesitate. The [glossary](https://fillthelobby.com/glossary#good-faith-estimate) defines the term in one line if you need it for your own staff.

## Sources

- [eCFR — 45 CFR 149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610), checked 15 September 2026
- [CMS — What is a good faith health insurance estimate?](https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/medical-bill-guides-resources/what-good-faith-health-insurance-estimate), checked 15 September 2026
- [CMS — Sample notice of uninsured (or self-pay) individual's right to receive a Good Faith Estimate (PDF)](https://www.cms.gov/files/document/nsa-gfe-required-notice.pdf), checked 15 September 2026
- [CMS — Providers: payment resolution with patients](https://www.cms.gov/initiatives/no-surprise-billing/overview/policies-resources/providers-payment-resolution-patients), checked 15 September 2026
- [CMS — Dispute a medical bill](https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/dispute-medical-bill), checked 15 September 2026

## Good faith estimates: quick answers.

**Q: What is a good faith estimate?**

A written, itemized estimate of expected charges that providers must give uninsured and self-pay patients under federal No Surprises Act rules, when they book at least 3 business days ahead or ask about cost.

**Q: Do private-pay therapists have to give good faith estimates?**

Generally, yes. Clients who pay directly are self-pay, including those with insurance who don't have a claim submitted. One estimate can cover up to 12 months of recurring sessions if it sets out the expected frequency and number of visits.

**Q: When is a good faith estimate due?**

Within 1 business day if the patient booked 3 to 9 business days ahead, and within 3 business days if they booked 10 or more business days ahead or asked about cost.

**Q: What has to be on a good faith estimate?**

The patient's name and date of birth, a description of the service, an itemized list of expected services with codes and charges, the provider's name, NPI and tax ID, services scheduled separately, and statements that it is an estimate, not a contract, and can be disputed.

**Q: Is a price list on my website enough?**

No. A price list is public; a good faith estimate is a written document for one patient. The rules also require a notice on your website that estimates are available.

**Q: What happens if the final bill is higher than the estimate?**

If a patient is billed at least $400 more than the estimate, they can use the federal patient-provider dispute process for a bill dated within the last 120 calendar days. Issue a new estimate whenever the plan of care changes.

Reviewed September 2026.

## Keep reading.

## Want your pricing and notice set up properly?

## Related pages

- [Blog](https://fillthelobby.com/blog)
- [superbill](https://fillthelobby.com/blog/what-is-a-superbill)
- [showing prices on your website](https://fillthelobby.com/blog/functional-medicine-pricing)
- [How to show pricing on your website](https://fillthelobby.com/blog/functional-medicine-pricing)
- [What is a superbill?](https://fillthelobby.com/blog/what-is-a-superbill)
- [What is AI visibility, and how do you audit it for your practice?](https://fillthelobby.com/blog/ai-visibility-audit)
- [AI in healthcare marketing: what a private practice can use now](https://fillthelobby.com/blog/ai-in-healthcare-marketing)
- [Book a 30-minute call](https://fillthelobby.com/book)