Good Faith Estimate Generator for Self-Pay Patients

Build a Good Faith Estimate for a self-pay patient, and know when it is due.

List the services with codes and charges. You get a printable estimate, per-provider subtotals, the delivery deadline, a list of anything missing, a check of a bill against the $400 dispute line, and a review of which of your past estimates came in low.

Patient names and dates stay on this page. Nothing is sent anywhere, and nothing is saved.

1. Provider or facility

Name

NPI (10 digits)

Tax ID (TIN)

Address

2. Patient and dates

Patient name

Date of birth

How did this come about?

Date scheduled (or date the patient asked)

Expected date of service

Date prepared

Treat U.S. federal holidays as non-business days (an assumption; untick to count them)

Primary service, in plain language

3. Expected items and services

One line per item you expect to bill. Put a name in the last column when a different provider or facility will bill that line; their lines are totalled separately, because the $400 dispute test applies to each biller on its own.

Other providers or facilities may also bill for this care

Who they are and what they may bill Notes for the patient (optional)

The estimate

Check a bill against an estimate

Estimated by this provider or facility ($)

Billed by that provider or facility ($)

Date of the bill (optional)

Learn from your past estimates

One line per service, as case, code, estimate, actual. Use any case label; it is only used to add up lines that belong together. Remove patient names.

Past estimates and what was billed

Questions people ask

Who has to give a Good Faith Estimate?

Under the No Surprises Act, a provider or facility that schedules care for an uninsured patient, or for a patient who is insured but not using insurance, has to give an estimate of expected charges. The generator builds the document and works out when it is due. Whether a given patient or service is covered is for you and your advisor to decide.

When does the estimate have to be delivered?

The tool uses the commonly stated timing: within 3 business days of scheduling when care is booked 10 or more business days ahead, within 1 business day when it is booked 3 to 9 business days ahead, and within 3 business days of a request when the patient asks before scheduling. Care booked under 3 business days ahead is outside the scheduled-care rule. It counts the days strictly between scheduling and service and can treat federal holidays as non-business days. Check the dates against the current rule.

What is the $400 dispute threshold?

If a provider or facility bills the patient $400 or more above its estimate, the patient may start the patient-provider dispute resolution process, within 120 calendar days of the date of the bill. The bill-versus-estimate check on this page applies that test to one provider at a time.

What does the history check do?

Paste past estimates and what you actually billed, one line per service: case, code, estimate, actual. It shows how many of those cases would have crossed the $400 line and which codes you most often under-quote, so you can correct the basis of your estimates. It does not tell you what to charge.

Is this legal advice, and is this the official CMS form?

No to both. It lists the items the rule asks for in one document you can print or paste into your own system. CMS publishes its own template and notice wording; compare the output with it. Coding, charges, co-provider rules and enforcement are yours to confirm.

Not decided

Whether a patient or a service is covered by the rule, the correct codes and charges, the exact required notice wording (compare with the template CMS publishes), the separate co-provider estimate rules, state requirements, and how the delivery days are counted by a regulator. The deadline is an assumption you can see, not a ruling. Defaults are placeholders, not a fee schedule.