Sample Good Faith Estimate Notice

Note to providers: Providers may use this sample Good Faith Estimate Notice to comply with the No Surprises Act. The Act requires providers to inform their uninsured and private pay patients that they have a right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed. This Notice (not the Estimate itself) must be prominently displayed on the provider’s website and in the office (if the provider has a website or office) and at any on-site location where scheduling or questions about the cost of health care occur, if applicable.

Notice to clients and prospective clients:

Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, or how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises.