Free Good Faith Estimate template for therapists

Self-pay clients get a Good Faith Estimate before care starts. Enter the services you expect over the next few months and save an estimate with every field and disclaimer the No Surprises Act requires: your NPI and tax ID, codes and expected charges, and the client’s right to dispute a bill that runs $400 over.

FreeNo sign-upRuns in your browser, nothing you type is sent to us

Your practice

Saved in this browser

Client and care

Expected services

Service 1
Service 2

Scheduled separately and issue date

Before you send it

Everything checks out
  • PassEvery required field is filled in
  • NoteGive it on timeWithin 1 business day when the visit is booked 3 to 9 business days out, and within 3 business days when it is booked 10 or more out or when the client asks.

Good Faith Estimate

For a client who is uninsured or not using insurance.

Client
Name
Alex Rivera
Date of birth
April 12, 1988
Provider
Name
Jordan Lee, LMHC, Bayside Counseling
NPI
1234567893
Tax ID
12-3456789
Location
200 Central Ave, Suite 410 St. Petersburg, FL 33701

Primary service

Individual psychotherapy for anxiety, weekly 60-minute sessions, after a first intake session.

Starting November 10, 2026. This estimate covers the next 6 months of care.

CodeServiceDxEachQtyExpected
90791Psychiatric diagnostic evaluation (intake)F41.1$200.001$200.00
90837Psychotherapy, 60 minutes (53 or more)F41.1$165.0024$3,960.00
Total expected charges$4,160.00

Scheduled separately

A psychological evaluation, if recommended, would be scheduled separately and estimated on its own. You will get a separate Good Faith Estimate when these are scheduled or when you ask for one.

Please read

There may be other items or services we recommend as part of your care that must be scheduled or requested separately. They are not on this estimate.

This is only an estimate of the items and services reasonably expected at the time it was issued. Actual items, services or charges may differ.

You have the right to start a patient-provider dispute resolution process if you are billed at least $400 more than the total expected charges on this estimate ($4,560.00 or more). You must start it within 120 calendar days of the date on the bill. For information, visit www.cms.gov/nosurprises or call 1-800-985-3059.

This Good Faith Estimate is not a contract and does not require you to get these items or services from us.

Keep a copy of this estimate, or take a picture of it.

Made with the free good faith estimate generator from dailybuilt · dailybuilt.co/tools/good-faith-estimate-generator/

How to use it

  1. 1Enter your practice details once. They stay saved in this browser.
  2. 2Add the client, a plain description of the care, and how many months the estimate covers.
  3. 3List each expected service with its code, diagnosis, charge and how many times you expect it.
  4. 4Fix anything the checker marks, then save it as a PDF and give the client a copy.

Questions

Who needs a Good Faith Estimate?

Under the No Surprises Act, providers give one to clients who have no health coverage and to clients who have coverage but are not using it for your services. HHS has deferred enforcement for clients who will file a superbill with their plan.

When do I have to give it?

Within 1 business day after scheduling when the service is at least 3 business days away, within 3 business days when it is at least 10 business days away, and within 3 business days of a client asking for one.

Can one estimate cover a whole course of therapy?

Yes. For recurring services you can issue one estimate that covers up to 12 months, with the expected number of sessions. Issue a new one if the care changes or runs past 12 months.

What happens if I bill more than the estimate?

If the bill is at least $400 more than the total expected charges, the client can start the federal patient-provider dispute resolution process within 120 days of the bill.

Do you see what I type?

No. The estimate is built in your browser and never sent to dailybuilt. Your practice details are saved in this browser for next time; client details are not saved.

How long do I keep a copy?

Keep a copy of every Good Faith Estimate you issue for at least 6 years.

What a Good Faith Estimate has to include

  • The client’s name and date of birth.
  • A plain-language description of the primary service and when it is scheduled.
  • Each expected item or service, with service codes, diagnosis codes and expected charges.
  • Each provider’s name, NPI, tax ID and the location where the care happens.
  • Any services you expect to schedule separately.
  • The four disclaimers: other services may be recommended, it is only an estimate, the right to dispute, and it is not a contract.

The full rules, deadlines and a worked example: Good Faith Estimates for therapists.

Clients who file with their plan need a superbill instead. Make one with the free superbill generator.

More free tools

Therapy practicesSuperbill generatorFill in a visit, check it for denial risks and save a PDF your client can file.Open the tool Therapy practicesPsychotherapy CPT time calculatorEnter session minutes and get the psychotherapy code the time supports.Open the tool Therapy practices8-minute rule calculatorTurn timed therapy minutes into billable units, code by code.Open the tool
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Good Faith Estimates for therapists, explained

Who gets a Good Faith Estimate, the ten things it must include, the deadlines, and the $400 dispute rule for self-pay therapy clients, in plain English.

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