Private practice · uninsured and self-pay clients · reviewed 28 August 2026
Good Faith Estimate preparation worksheet
A preparation pass that helps a therapist gather the required facts before producing a client-facing Good Faith Estimate.
Use the resource →Use when an uninsured or self-pay person schedules care at least three business days ahead, asks for an estimate, or raises a question about cost.
This is not itself the estimate and should not be handed to a client as a substitute for the required written or electronic Good Faith Estimate.
Recheck the source links before relying on an older saved copy. Entries stay in this open page. Copy or print the working copy before leaving.
Working resource
Make the invisible facts visible.
Review point 01
Confirm why the person is self-pay
Record whether the person has no coverage or does not intend to submit the scheduled service to coverage. Do not infer the answer from silence.
Review point 02
Capture the trigger and due date
Record the request or scheduling date, the service date, and the delivery deadline. CMS distinguishes requests from services scheduled at least three business days ahead.
Review point 03
Describe the primary service
Write the scheduled or requested service, date range if known, and diagnosis information if it has been determined. Do not invent a diagnosis to complete a field.
Review point 04
Estimate the course and expected charges
List each reasonably expected item or service, its expected charge, and the expected total. For recurring therapy, state the assumptions that produce the estimate.
Review point 05
Add the required notices
Use the CMS sample and 45 CFR 149.610(c) as the completion standard, including the estimate-not-a-contract and dispute-right information.
Review point 06
Preserve what was delivered
Keep the dated estimate and the later bill. CMS may ask for both if the client starts the federal patient-provider dispute process.
Private working copy
Carry the review into your own next action.
Your entries remain only in this open page. They are not saved, uploaded, transmitted, or placed in the URL. Use a non-identifying reference—not a client name.
Your working copy
Controlling material
Read the authority, not merely the worksheet.
Educational information only; not legal, clinical, tax, billing, or regulatory advice. A resource cannot resolve facts it was not given or authority that changed after the review date.
