Free Good Faith Estimate template for therapists

This tool needs JavaScript. It runs entirely in your web browser, so it can't work with JavaScript turned off. Turn it on and reload the page to make an estimate. Below is what an estimate must include and when it's due. Providers can also list their practice on Cima Find Care.

When the estimate is due

Scheduled 10 or more business days aheadWithin 3 business days of scheduling
Scheduled 3 to 9 business days aheadWithin 1 business day of scheduling
The client asks for oneWithin 3 business days of the request
Something changesA new estimate at least 1 business day before the visit

Scheduled less than 3 business days ahead? No estimate is due at scheduling, but one is still due within 3 business days if the client asks. For ongoing therapy, one estimate can cover up to 12 months; give a new one for care past that.

Nothing you type leaves your computer. This page builds the estimate right here in your browser. Nothing is sent to us or anyone else, and your client's details are never saved: close the tab and they're gone.

Provider and practice

Provider's name Credential Provider's NPI Provider's tax ID (TIN) Practice or facility name if different from you Practice NPI (Type 2) if any Practice tax ID if different Office address City, state and ZIP Where the sessions happen Phone Email

Remember my practice details on this computer

Saves only the provider and practice fields above, in this browser, so you don't retype them. Client details are never saved. Untick to forget them.

Client

Client's name Date of birth Date of this estimate

The main service

Describe it in plain words First scheduled date if scheduled Schedule optional

Diagnosis codes (ICD-10) up to four, for example F41.1

Diagnosis code A Diagnosis code B Diagnosis code C Diagnosis code D

Services and expected charges

One line per kind of service. Use your self-pay rate, after any sliding-scale discount. For ongoing therapy, set sessions a month and months (12 at most), and the estimate shows the math.

More optional Services you expect to schedule separatelyOne per line. They print as a list with the notice the rule requires: separate estimates will follow. Notes for the client

Preview

"Download PDF" opens your browser's print window: choose "Save as PDF" as the printer. Only the estimate prints, on a plain US Letter page. Give the client a copy on paper or by email, whichever they ask for, and keep one in their record.

Free online booking, too

List your practice on Cima Find Care, free, and clients book open times from your listing, any hour, instead of leaving a voicemail. We never take a cut of your sessions.

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Who gets a Good Faith Estimate

The No Surprises Act gives a right to a Good Faith Estimate to clients who are uninsured, and to clients who have insurance but choose not to use it for your services (self-pay). In a therapy practice that's often most of your private-pay clients, and anyone you're out of network with who pays you directly. It doesn't cover clients using Medicare, Medicaid, CHIP, TRICARE or VA care, which have their own billing protections.

You also have to let people know estimates are available: ask clients whether they have insurance and plan to use it when they schedule, tell self-pay clients they can get an estimate, and post a notice that says so on your website and in your office, where people schedule or ask about cost.

What the estimate must include

The rule (45 CFR 149.610) lists what goes on it. This tool includes each one:

The client's name and date of birth.
A plain-language description of the main service, and the date it's scheduled, if it is.
An itemized list of the services you reasonably expect to provide, grouped by provider or facility, each with its service code, diagnosis codes and expected charge.
The name, NPI and tax ID of each provider and facility on it, and the state and office location where the services happen.
A list of any services you expect to schedule separately, with a notice that separate estimates will follow.
The required disclaimers: other services may be recommended and estimated separately; it's only an estimate and actual charges may differ; the client can start a dispute if billed substantially more (CMS uses $400 or more over the estimate), and doing so won't affect their care; where to learn how (cms.gov/nosurprises); and that it isn't a contract and doesn't require them to get the services. It also tells the client to keep a copy, as CMS's model notice does.

Give it in writing, on paper or electronically as the client prefers, in a form they can save and print. It becomes part of the client's record, and you must give a copy of any estimate from the last six years if they ask.

Ongoing therapy: one estimate for up to 12 months

For care that repeats, like weekly sessions, one estimate can cover up to 12 months, as long as it shows the expected scope: how often, for how long, and how many sessions in all. That's why each line here has sessions a month, months and a fee, and prints the math, for example 4 sessions a month for 12 months is 48 sessions at $150, or $7,200. Before the 12 months run out, give a new estimate for the next stretch of care, and give a new one sooner if the plan of care or your fee changes.

If a client is billed more than the estimate

If a client's bill from any provider or facility on the estimate is $400 or more over that provider's or facility's estimated amount, the client can start the patient-provider dispute resolution process with the U.S. Department of Health and Human Services. They must start within 120 calendar days of the date on the original bill, and CMS lists a $25 fee. While a dispute is open, the bill can't be sent to collections. The simplest fix is usually to correct the bill: if your plan of care changed, give a new estimate before the extra sessions rather than after.

Clients who use insurance out of network don't need an estimate; they need a superbill. Make one with the free superbill maker. For what clients need to know about paying for therapy themselves, see our guide to self-pay and Good Faith Estimates.

General information, not legal advice. The rules can change: check cms.gov/nosurprises for current requirements.

Questions

Who needs a Good Faith Estimate?

Clients who are uninsured, and clients who have insurance but aren't using it for your services. Give one when they schedule (if it's at least 3 business days ahead) or whenever they ask. Clients using Medicare, Medicaid, CHIP, TRICARE or VA care aren't covered by this rule.

Is this Good Faith Estimate tool really free?

Yes. There's no sign-up, no email and no limit on how many you make. Cima Find Care offers it to Texas providers; if you'd like clients to find and book you online, you can list your practice, but you never have to.

Is what I type private?

Yes. Nothing you type leaves your computer: the page builds the estimate in your browser and sends nothing anywhere. Client details are never saved. Only if you tick "remember my practice details" are your provider and practice fields kept, in this browser only.

What if my client is billed more than the estimate?

If the bill is $400 or more over the estimate for any provider or facility, the client can start a dispute with the U.S. Department of Health and Human Services within 120 calendar days of the date on the bill, at cms.gov/nosurprises or 1-800-985-3059. Starting one can't affect the care they get. To avoid it, give a new estimate before care changes, and correct a bill that's over.

Do I need a new estimate every year?

For ongoing therapy, one estimate can cover up to 12 months. Give a new one for care past that, and sooner if the services, the providers or your fee change: a new estimate is due at least 1 business day before the changed visit.

More free tools: Superbill maker · All free tools for Texas providers

Sources

General information, not legal advice. Check cms.gov for current requirements before you rely on it.