No Surprises Act

Good Faith Estimate template for therapists

Give uninsured and self-pay clients an itemized estimate of expected costs. Fill in the form below and download a PDF with the required disclaimer.

Create a Good Faith Estimate

What the estimate includes

Client name and date of birth
A clear description of the main service
Itemized services with CPT codes and expected charges
Diagnosis codes, if known
Your name, NPI, tax ID and location
The client's right to dispute a bill that is $400 or more above the estimate

Good Faith Estimate generator

Created on this device. Nothing you type is sent to our servers.

Provider

Name and credentials Practice name Optional Address Phone NPI Tax ID (EIN) License number and state Email Optional Default session fee

Remember provider details on this device

Client and period

Client name Date of birth Diagnosis (ICD-10) If known Date issued Estimate from Estimate to Up to 12 months Primary service Expected frequency

Expected services

Additional notes Optional, e.g. other providers or services scheduled separately

About the Good Faith Estimate

Since January 1, 2022, the No Surprises Act requires health care providers, including therapists and counselors, to give a Good Faith Estimate of expected charges to clients who are uninsured or who choose not to use insurance.

If the final bill is at least $400 more than the estimate, the client can start a patient-provider dispute resolution process within 120 days of receiving the bill. Keeping estimates accurate and updated protects both you and your client.

Clients who use their insurance out of network usually need a superbill instead.

Keep every estimate in one place

SuperbillKit Pro will store client estimates and superbills, remind you when a 12-month estimate expires, and add your logo.

$12 / month