Free tool for therapists
Good Faith Estimate template for therapists
Fill it in, download a PDF based on the CMS model form, and hand it to your self-pay client. Free, and nothing is stored.
Your client’s details never leave your browser. We don’t see or store them.
What a Good Faith Estimate is, and who needs one
A Good Faith Estimate (GFE) is a written estimate of what a client can expect to pay for your services, and a good faith estimate template saves you rebuilding it for every client. It comes from the federal No Surprises Act, and it applies when a client has no insurance or is choosing not to use it for their care. You can read the official rules in the CMS guidance on Good Faith Estimates.
If you see self-pay clients, you are expected to give each one a GFE when they schedule, or within 3 business days if they ask for one. It should list your fees, the services you expect to provide and the dates, in writing, before care begins.
It is an estimate, not a contract. If the final bill ends up $400 or more above the estimate, the client can start a dispute process with the federal government. Keeping the estimate close to what you really expect to charge protects both of you.
Good Faith Estimate example for a therapy practice
Here is what a filled-in estimate can look like. The practice and client are made up.
| Client | Jane Doe (date of birth 01/15/1990) |
|---|---|
| Provider | Example Counseling, LLC (fictional practice) |
| Provider NPI and TIN | NPI 0000000000, TIN 00-0000000 |
| Service | Individual therapy, 53 minutes or more |
| CPT code | 90837 |
| Diagnosis code | None provided |
| Schedule | Weekly sessions for 12 months, 52 sessions |
| Fee per session | $150.00 |
| Estimated total for 12 months | $7,800.00 |
| Date estimate made | 03/01/2027 |
What your Good Faith Estimate must include
- Client name and date of birth
- Description of the services
- CPT codes
- Diagnosis codes, if known
- Expected charges for each service
- Provider name, NPI and TIN
- The date the estimate was made
- The dispute notice
How to fill in your Good Faith Estimate, step by step
- Add your practice details. Enter your practice name, your NPI and your TIN. The NPI and TIN print on the estimate so your client can see who the provider is.
- Add your client’s details. Enter your client’s name and date of birth. These stay in your browser and are not sent to us.
- Choose the services and CPT codes. Pick each service you expect to provide, such as individual therapy with CPT 90837. Add a diagnosis code if you have one. It is optional.
- Set how often and for how long. Choose weekly, every other week or monthly, and how many months the estimate should cover, up to 12.
- Enter your fee per session. Type in your fee for each service. The tool works out the number of sessions and the estimated total for you.
- Download the PDF and give it to your client. Download your Good Faith Estimate, check it over, and give your client a copy within the time that applies. Keep a copy for 6 years.
Good Faith Estimates for recurring therapy sessions
One estimate can cover up to 12 months of recurring sessions, so you do not need a new one every month for a client who sees you every week.
For weekly sessions, count about 52 sessions across 12 months and multiply by your fee. For sessions every other week, count about 26. If your client may stop sooner, estimate for the length of care you actually expect, not the full 12 months.
Issue a new estimate when your fee changes, when you add a new service such as a second weekly session or a different CPT code, and once the 12 months are up.
Couples, family and group therapy
Couples therapy. Give the estimate to the client who is scheduling and paying for the sessions. List the service as couples or family therapy with its CPT code, for example 90847 when both partners attend, and use your fee for that service. If you are unsure whether each partner needs their own, ask your licensing board or a compliance adviser.
Family therapy. The estimate goes to the person who is the client or who is responsible for the bill, such as a parent. List the family session as its own service with the right CPT code, and add a separate line if you also plan individual sessions for the same client.
Group therapy. Each group member who is self-pay gets their own estimate. List group therapy as its own service, usually CPT 90853, with your per-session group fee and the number of sessions you expect them to attend.
What happens if your bill is higher than the estimate
If the final bill is $400 or more above the Good Faith Estimate, your client can start a dispute through the federal patient-provider dispute process. An independent reviewer looks at the estimate and the bill, and the client does not need a lawyer to ask for it.
You can avoid this in two ways. Estimate a little high rather than exactly on the line, so a few extra sessions do not push the bill over. And update the estimate in writing when something changes, such as a higher fee or a new service.
If you offer a sliding scale, base the estimate on the fee that client will actually pay. Our sliding scale fee calculator can help you set one.
When you don’t need a Good Faith Estimate
You generally do not need one for a client who is using their insurance for in-network care. Their plan sends them an Explanation of Benefits instead.
Out-of-network clients who pay you themselves usually do need one, because they are not using insurance for that care. If a client is not sure how they want to pay, it is safer to give them an estimate.
If your client has out-of-network benefits and wants to be reimbursed, they will need a superbill from you. Our free superbill template can help with that.
Rules can change, so check current CMS guidance.
Common mistakes therapists make
- Leaving out your NPI or TIN. Both belong on the estimate.
- Skipping the diagnosis code field. It is optional if you do not have one yet, but add it when you do.
- Not keeping a copy for 6 years. Save the PDF with the client’s record.
- Forgetting the dispute notice. The CMS model form includes it, so do not remove it.
- Giving it late. Count the business days from when the session was booked or when the client asked.
Frequently asked questions
Providers who see clients who are uninsured or who are paying out of pocket instead of using insurance. That includes solo therapists and group practices. Clients who are using their insurance get an Explanation of Benefits from their plan instead. If you are not sure which applies, ask the client how they plan to pay before you book.
If the first session is at least 10 business days away, the estimate is due within 3 business days of scheduling. If it is 3 to 9 business days away, it is due within 1 business day. If a client asks for one before they book, it is due within 3 business days of the request. Put the due date in your calendar when you book so it is not missed.
For ongoing weekly or monthly sessions, a single estimate can cover up to 12 months. After that, or if the client’s care changes a lot, you issue a new one. If your fee changes, it is worth updating the estimate too. A new estimate is also a good moment to talk through fees with your client.
No. The PDF is made in your browser, so your client’s name, date of birth and diagnosis code stay on your device. We only receive your first name, email, practice name and city when you download. Once you have the PDF, there is nothing of your client’s for us to delete, because we never had it.
No. This tool follows the layout and wording of the standard CMS form, but we are a marketing agency, not a law firm. If you are unsure whether a client needs a GFE or how to fill one in for an unusual case, check with your licensing board, professional association or a compliance adviser. Rules can change, so check current CMS guidance before you rely on this page.
Yes. This page fills in the fields of the CMS model form for you and gives you a PDF you can hand to your client.
A Good Faith Estimate is required for clients who are uninsured or paying out of pocket. Give it within 1 business day if the session is booked 3 to 9 business days ahead, within 3 business days if it is booked 10 or more business days ahead, and within 3 business days of a request. A recurring estimate can cover up to 12 months. A client can dispute a bill that is $400 or more above the estimate. Keep a copy for 6 years. This is general information, not legal advice.
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