Free tool
Free Good Faith Estimate builder
Build a plain-text Good Faith Estimate for self-pay clients from the codes and fees you type in. Everything runs in your browser, nothing is sent or stored, and the tool never suggests or assigns a code.
A template aid, not legal advice. You type every code, unit and fee yourself. The tool only formats what you enter into one printable document; it does not check your fees against any fee schedule and does not decide what your practice should charge. See the current notice on the CMS No Surprises Act page.
Your estimate
Plain text, ready to copy into your own letterhead or print on paper.
Privacy: the estimate is built entirely in your browser. Your inputs are not transmitted, stored or logged; there are no cookies and no external requests. More on Privacy and security.
Good to know
- The estimate covers the services you list for 12 months from the start date.
- Keep a copy of the estimate you gave the client in the record.
- Add what 45 CFR 149.610(c) also asks for when you give it to a client: the client's name and date of birth, diagnosis codes where you use them, your TIN and the service location.
- This page is a template aid and no legal advice, check the current CMS notice on the CMS No Surprises Act page.
Report Copilot for your notes
Drafted from your own notes: treatment plans, plan reviews, continued-care letters and record-request packs. Every sentence sourced to your documentation.