A Good Faith Estimate template for therapists is a written form for showing an uninsured or self-pay client the expected cost of planned therapy services. It should identify the services, dates or estimated frequency, per-session charges, and projected total, while making clear that the figure is an estimate rather than a guarantee of the final bill.
What a Good Faith Estimate Means
Under the federal No Surprises Act, people who do not have health insurance, or who choose not to use their insurance for a service, can generally ask for a Good Faith Estimate of expected charges. A therapist who provides a scheduled service may need to give one under the applicable federal rules. The estimate is meant to help a client understand anticipated costs before receiving care, not to prescribe treatment or promise that every future appointment will happen exactly as projected.
A GFE is different from a receipt, superbill, or treatment plan. A receipt records a charge already made. A superbill summarizes services that have already taken place, often for a client to submit to an insurer. A treatment plan describes clinical goals and possible care. A GFE looks ahead and puts expected charges in writing. A practice may use one document for more than one purpose, but it should label the estimate clearly and include the information required for the estimate.
The estimate should be based on services and charges that are reasonably expected when it is prepared. Therapy can change as a client’s needs, schedule, and goals change. That is why a careful estimate states its assumptions, such as an expected number of sessions or a time period, rather than implying that an uncertain course of care is fixed.
Who Should Receive One
The federal GFE protections are generally for an uninsured person or a person who is choosing to self-pay rather than submit a claim to insurance. A client who uses insurance for a covered service follows a different process for learning about plan benefits and cost sharing. If someone has insurance but elects to pay out of pocket for a particular service, the practice should clarify how the client is being treated for that service and provide the estimate information that applies.
Therapists can make the process part of intake: ask whether the client plans to use insurance or self-pay, explain the fee schedule, and record whether the client requested an estimate. A client does not have to wait for a therapist to offer a particular form before asking about expected charges. The practice should also consider whether other providers or services are expected as part of the scheduled care; when another provider is known to be involved, the estimate process may require coordination.
Federal and state requirements can interact, and a therapist’s role may depend on the service, setting, and billing arrangement. If a practice is unsure how a rule applies to its circumstances, ask a qualified professional.
When and How to Provide the Estimate
Federal timing rules depend on when the appointment is scheduled or when the client requests an estimate. In general, for a service scheduled at least 10 business days ahead, the provider must give the estimate within three business days after scheduling. If the service is scheduled 3 to 9 business days ahead, the deadline is generally one business day after scheduling. When a client requests an estimate without scheduling, the provider generally has three business days to provide it. Different details can apply when an appointment is scheduled fewer than three business days in advance.
Give the document in writing, on paper or electronically, in the format the client requests when possible. Keep a copy and note when it was sent. A useful workflow is:
- Confirm whether the client is uninsured or intends to self-pay for the service.
- Identify the expected service, provider, location, and likely schedule.
- Calculate the expected charges using the current fee schedule and state the assumptions behind the total.
- Send the estimate within the applicable timeframe, answer questions, and retain the version provided.
- Update the estimate when a material change in expected services or charges is known, and explain what changed.
An estimate is not a substitute for discussing the fee before care begins. Explain how the practice bills for late cancellations, missed appointments, or other policies separately and plainly. Do not quietly fold a possible fee into an expected therapy charge if it is not reasonably expected to occur.
Good Faith Estimate Template
Copy this general form and complete the fields that apply. Use the practice’s actual identifying and billing details, current fees, and a realistic estimate period. A service or billing code can be included where applicable; do not guess at a code. This sample form is a practical starting point, not a guarantee that every field meets every situation’s requirements.
| Field | Information | ||
|---|---|---|---|
| Estimate prepared on | |||
| Client name | |||
| Provider or practice name | |||
| Provider identification details, as applicable | |||
| Service location or delivery format | |||
| Expected service and description | |||
| Service or billing code, if applicable | |||
| Expected date, frequency, or estimate period | |||
| Expected item or service | Quantity | Charge per item | Expected total |
| Estimated total for listed services | |||
| Assumptions or exclusions | |||
| Contact for estimate questions | |||
Sample only — fictional details: Client: Morgan Lee. Provider: Cedar Path Therapy, a fictional practice. Service: individual psychotherapy, 50 minutes, in person. Estimate period: four weekly sessions. Expected charge: $150 per session × 4 sessions = $600 estimated total. Assumption: the estimate covers only the four listed sessions; any later services would need their own cost discussion and, where applicable, an updated estimate. These names and figures are illustrative, not a fee recommendation.
How to Calculate and Explain the Total
For a straightforward example, suppose a therapist expects to provide four weekly sessions at $150 each during the first month. The estimated total for those sessions is $600. If an intake appointment has a different fee and is expected in addition to those sessions, list it as a separate line rather than hiding it in a general total. The same approach works for a longer period: show the number of anticipated appointments, the rate for each type of service, and the arithmetic behind the projected cost.
Make the estimate understandable to someone who is not familiar with billing terminology. Explain whether the listed amount is per session or for the whole period, identify any separate service, and state what is not included. If the appointment frequency is uncertain, say so and use a reasonable stated assumption—for example, “up to four weekly visits during the first month”—instead of presenting a speculative year of weekly sessions as a certainty.
Include provider and service details that the applicable rules call for, such as the provider’s identifying information, service description, expected date or period, and charges. Diagnosis or service codes may be relevant where known or applicable, but a template should not encourage anyone to invent them. Keep the document consistent with the practice’s actual fee schedule and billing records.
What the Estimate Does and Does Not Promise
A GFE is an advance estimate, not a contract requiring a client to attend every projected appointment. It is also not a promise that the client’s clinical needs, appointment frequency, or total care will remain unchanged. If care changes, the therapist should explain the new expected services and costs before proceeding when practicable and follow the rules that apply to the updated situation.
It is also not an insurance coverage decision. For self-pay care, the estimate helps the client anticipate what the provider expects to charge; it does not determine whether an insurer would reimburse the client or whether a service would be covered under a plan. A practice should avoid describing an estimate as “insurance approved” unless that is genuinely established through the relevant process.
Federal rules provide a patient-provider dispute resolution process for certain uninsured or self-pay clients whose bill is substantially above the estimate. In general, a client may be able to use that process when the bill from a provider or facility is at least $400 more than that provider’s or facility’s GFE, and the request must be made within 120 calendar days of the initial bill. This is a specific dispute process, not a reason to omit clear estimates or to assume every difference qualifies.
Common Problems to Avoid
- Leaving the time period vague: “ongoing therapy” does not tell a client what amount of care the total represents. State a date range, visit count, or other clear assumption.
- Showing only a grand total: Break out session types, quantity, rate, and expected subtotal so the client can check the calculation.
- Using outdated fees: Check the rate against the current fee schedule before sending the estimate and document the version provided.
- Confusing estimate and policy: Identify possible cancellation or missed-appointment charges in the practice’s policy; distinguish them from expected charges for scheduled services.
- Overstating certainty: Avoid language suggesting that a projected number of sessions is guaranteed or clinically required. Describe it as an estimate based on stated assumptions.
- Forgetting a known additional provider: If other services or providers are expected as part of the scheduled care, check whether they need to contribute information to the estimate.
- Failing to keep a copy: Retain the sent estimate and a record of its date so the practice and client can refer to the same version.
Frequently Asked Questions
Do therapists have to provide a Good Faith Estimate?
Federal rules generally require providers to give an estimate to uninsured people and people who choose to self-pay for scheduled services, and when such a person requests one. The exact requirements and timing depend on the circumstances.
How far in advance should a therapist send the estimate?
For a request or scheduled service, the federal deadlines generally range from one to three business days, depending on how far ahead the appointment is scheduled. A service scheduled fewer than three business days away can be treated differently, so check the applicable rule rather than relying on a single deadline for every case.
Is a Good Faith Estimate the same as a superbill?
No. A GFE looks ahead at expected charges. A superbill typically records services already provided and the associated charges, often for possible insurance reimbursement.
Does the estimate guarantee the total cost of therapy?
No. It reports charges reasonably expected for the services and assumptions listed. New services, a changed schedule, or a longer course of care can change the total, so explain updates clearly.
What if the bill is higher than the estimate?
First compare the bill with the estimate and check which provider or facility charged each amount. Under federal rules, certain clients may use the patient-provider dispute resolution process when a bill is at least $400 above that provider’s or facility’s estimate; a request generally must be made within 120 calendar days of the initial bill.
Can a therapist use this template for every client?
It is a general starting point, not a universal compliance form. Adapt it to the client’s payment choice, services, location, provider details, and any applicable federal or state requirements.