Good Faith Estimate Template

Understand how a Good Faith Estimate Template works and how it can help patients estimate their medical costs.

By Ericka Pingol on Apr 08, 2024.

Fact Checked by Nate Lacson.

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What is a Good Faith Estimate Form?

A good faith estimate is a document that healthcare providers give to help patients understand their estimated out-of-pocket costs for a particular medical procedure. This is an invaluable resource for helping people make informed decisions about their care. It allows patients to compare the estimated costs with the cost of alternative treatments and choose the best options for their budget.

A makes it easy to provide accurate and detailed estimates of medical costs. It generally includes the patient's information, a breakdown of the medical services and estimated costs, and an explanation of any additional fees or charges. This helps patients understand how much they will need to pay for their care. It also allows healthcare providers to set expectations and ensure patients know of additional fees they may encounter during their care.

Printable Good Faith Estimate Template

Download this Good Faith Estimate Template to calculate predicted costs for patients.

How does a Good Faith Estimate Template work?

Our free printable Good Faith Estimate Template allows you to provide your patients with an accurate and detailed estimate of their medical costs quickly. The template includes sections for the patient's information, diagnoses, services, and estimated costs of treatments.

You can use this free template by following the steps below:

Step One: Download the form

Get a copy of the Good Faith Estimate template using the link provided on this page. You can also access it from the Carepatron app or our resources library.

Step Two: Enter patient information

Enter the patient's name, address, and other relevant contact information. You also need to enter their diagnosis and any treatments they are receiving.

Step Three: Write down services and costs

Indicate the services you will provide for the patient, along with an estimated cost.

Step Four: Calculate the total cost

Once you have listed all of the services and estimated costs, add them up to get the total cost for the patient. Be sure to include any taxes or additional fees that may be applicable.

Step Five: Discuss the estimated costs with your patient

Explain to your patient the total cost of their services and any additional fees that may be applicable. Be sure to discuss any payment options they may have.

Good Faith Estimate Template example (sample)

We have written a Good Faith Estimate Template PDF example to illustrate how to use this form. It showcases how to fill in each section, allowing you to better understand how a good faith estimate works. You can view it here or download the PDF as a reference.

Download the free Good Faith Estimate Template example (sample)

Good Faith Estimate Template example (sample)

When would you use a Good Faith Estimate Template?

You can use a printable Good Faith Estimate Template anytime you need to provide a patient with an estimate of what services and treatments might cost. You can also use it to:

Calculate the total cost of services before beginning treatment

A Good Faith Estimate Template is essential if you’re working with a patient who needs to plan out their healthcare expenses. You can use it to provide a total cost of services before you begin treatment so that there are no surprises when it’s time to pay the bill.

Discuss the patient's expected responsibility for payment

Using a Good Faith Estimate Template is also helpful for discussing the patient’s expected responsibility for payment. This includes any out-of-pocket costs and other financial considerations.

Identify and explain any additional fees

A Good Faith Estimate Template lists any additional fees, such as supplies and lab tests. This allows you to explain why the patient is being charged for those fees and what they include.

Benefits of a Good Faith Estimate Template

Our free Good Faith Estimate Template can help ensure that you and your patient clearly understand the charges associated with treatment. Here are some of its other benefits:

It's fully digital

Our free template is available for you to download and customize in any way. You can also store it on the web or your computer for fast access and easy editing.

It's comprehensive

This Good Faith Estimate Template has all the general sections you need to explain your fees to your patient, including a breakdown of the different components.

It gives patients a clear picture of estimated costs

A Good Faith Estimate Template will provide your patient with a clear and detailed picture of what their treatment is likely to cost. This helps them budget for their medical expenses and also enables you to communicate more effectively.

It's legally binding

Using this Good Faith Estimate Template to inform your patient of their expected costs will help protect you from any potential legal issues. Legal documents like these are essential for protecting both parties and can help avoid misunderstandings.

Who uses Good Faith Estimates?
Who uses Good Faith Estimates?

Commonly asked questions

Who uses Good Faith Estimates?

Healthcare providers use Good Faith Estimates to document the estimated costs of medical treatments and procedures. Patients can also use Good Faith Estimates to understand their financial responsibility for the healthcare services they are seeking.

When to send a Good Faith Estimate?

Providers should send Good Faith Estimates to their patients before treatment is rendered. This will help ensure that the patient understands what financial responsibility they are taking on and will also provide them with the opportunity to ask questions before treatment begins.

Is a Good Faith Estimate legally required?

In some cases, Good Faith Estimates may be legally required. This is typically the case for significant medical procedures and treatments expected to incur high costs. If a Good Faith Estimate is not provided, the patient may be entitled to legal action against the provider.

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