How do you write a Good Faith Estimate for an uninsured or self-pay patient?
Write it in this order: screen the patient, start the business-day clock, request co-provider data, fill every required field at your self-pay rates, add the disclaimers, deliver it in writing and file it. This post walks the document field by field, with a made-up sample and computed deadlines. The rule itself, 45 CFR 149.610, is explained on our reference page.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: a Good Faith Estimate is a written, itemized document, not a quote over the phone. Build it from the scheduling date, use your cash-pay rate as the expected charge, group every line by provider, and send it within the business-day deadline in a format the patient can save and print.
How do you write a Good Faith Estimate for a self-pay patient?
You write it in seven steps, and the order matters because the deadlines start before the document exists. Under 45 CFR 149.610(b)(1)(vi), the estimate is due 1 or 3 business days after scheduling, or 3 business days after a request. The content is set by 149.610(c)(1).
For definitions, who qualifies and CMS enforcement positions, see the Good Faith Estimate reference page. This post is the build sheet.
What are the seven steps, in order?
What goes in each field of the estimate?
| Field | What to enter | Common slip |
|---|---|---|
| Patient name and date of birth | As on the scheduling record | Nickname used instead of legal name |
| Primary service | Plain-language description and scheduled date, if one exists | Using code language the patient cannot read |
| Itemized list, grouped by provider | Every item you expect, then each co-provider's items, for the period of care | Items listed in one flat list with no billing provider |
| Diagnosis codes | ICD-10-CM codes expected for the visit | Leaving the diagnosis blank because it is not confirmed yet |
| Service codes | CPT, HCPCS, MS-DRG or National Drug Codes as the item requires | Mixing a DRG into a clinic estimate |
| Expected charge | Your cash-pay rate or self-pay rate, with any self-pay discount already applied | Quoting the full chargemaster price |
| Provider identifiers | NPI and TIN for each provider or facility, plus state and location | Leaving the NPI or TIN off a co-provider line |
| Separately scheduled care | A list of items expected before or after the visit that will need their own scheduling | Omitting follow-up imaging or labs |
What does a finished estimate look like?
The sample below uses made-up numbers for a family practice visit. It shows grouping by provider, one diagnosis, service codes and the expected charge for each line. The codes are real, but the dollar amounts and the practice are invented for illustration.
| Billing provider | Item | Code | Expected charge |
|---|---|---|---|
| Lakeside Family Practice (example) | Established patient visit, moderate complexity | CPT 99214 | $140.00 |
| Lakeside Family Practice (example) | Blood draw | CPT 36415 | $15.00 |
| Example Lab Partners (co-provider) | Complete blood count with differential | CPT 85025 | $22.00 |
| Total expected charges | $177.00 |
A line for the lab sits under its own billing provider, with its own NPI and TIN. Keep that grouping even when the patient sees only one front desk, because a later dispute compares totals provider by provider.
Which disclaimers must be on the document?
- Items or services you recommend later may need separate scheduling and are not in the estimate.
- A disclaimer directly above the list of separately scheduled care, saying separate estimates will be issued on scheduling or request.
- A statement that this is only an estimate and actual items, services or charges may differ.
- The patient's right to start the patient-provider dispute resolution process if the actual billed charges are substantially in excess, with instructions on where to find how.
- A statement that the estimate is not a contract and does not require the patient to use the providers or facilities named.
How do you count the deadlines? A worked example
A patient asks for an estimate on Friday, December 11, 2026. The estimate is due 3 business days after the request, which is Wednesday, December 16, 2026. You must contact the lab co-provider within 1 business day, by Monday, December 14, and the lab's data must reach you within 1 business day of receiving your request, by Tuesday, December 15. A different patient schedules a visit on Monday, December 7, 2026, for Friday, December 11. That is a primary service scheduled at least 3 business days ahead, so the estimate is due by Tuesday, December 8, 2026.
Check your own dates with our NSA deadline calculator. Business days skip weekends and federal holidays.
What if the plan of care changes before the visit?
Issue a new estimate. If the scope changes, a new estimate must reach the patient no later than 1 business day before the service is scheduled to be furnished (45 CFR 149.610(b)(1)(vii)). If a co-provider is swapped less than 1 business day before the service, the replacement accepts the replaced provider's estimate for those items.
For recurring services such as a series of treatments, one estimate can cover the series if it states the expected scope, and it cannot cover more than 12 months. After that, issue a new one.
How Nucleus Align handles Good Faith Estimates
We track the 1-business-day and 3-business-day clocks from the moment care is booked or a price question is asked, assemble the itemized estimate at your self-pay rates, and file it in the record. This sits inside our patient billing work and our family medicine billing support. To talk through your process, book a call.
- 45 CFR 149.610 Requirements for good faith estimates for uninsured (or self-pay) individuals · eCFR
- 45 CFR 149.620 Requirements for the patient-provider dispute resolution process · eCFR
- Overview of rules and fact sheets (model Good Faith Estimate notice) · CMS
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01How do you write a Good Faith Estimate for an uninsured or self-pay patient?
Screen the patient, log the scheduling or request date, ask co-providers for data within 1 business day, then fill the fields listed in 45 CFR 149.610(c)(1): identifiers, a plain description, itemized lines by provider, codes, expected charges, NPI, TIN and disclaimers. Deliver it in writing within the deadline.
02What rate do I use for the expected charge?
Use your cash-pay rate or the rate you set for uninsured and self-pay patients, with any discount for them already applied. 45 CFR 149.610(a)(2)(v) defines the expected charge that way, so the full chargemaster price is the wrong figure unless it is your self-pay rate.
03Can I give the estimate by phone?
Not on its own. If the patient asks for the information by phone, you may explain it orally, but you must still issue a written estimate, on paper or electronically, under 45 CFR 149.610(e)(2). An electronic copy must be one the patient can save and print.
04Do I need a new estimate if the provider changes?
Yes, when the scope changes. A new estimate must reach the patient no later than 1 business day before the service. If a co-provider is replaced less than 1 business day before, the replacement accepts the replaced provider's estimate for the relevant items.
05Is there a template I can use?
CMS publishes a model Good Faith Estimate notice and an abbreviated version on its No Surprises Act overview page. The regulation requires the content in 149.610(c)(1), not a particular form, so a template works if every required field and disclaimer is on it.
Talk to a billing lead.
A 20-minute call about your payers, volume and setup. Monday to Friday, 9am to 5pm Eastern.