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This form may be used by the health care providers and facilities to inform uninsured (or self-pay) individuals of the expected charges for receiving certain health care items and services. A good faith estimate must be provided within 3 business days upon request. Information regarding scheduled items
Below is an example of a good faith estimate form for uninsured (or self-pay) individuals who are expected to receive a bill for their care. This sample form highlights key information that is required by the No Surprises Act.
22 lut 2024 · A good faith estimate should include expected charges for the scheduled health care items and services, including facilities fees, hospital fees, and room and board provided by the provider or facility. Good faith estimates only list expected charges for a single provider or facility.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.
2 lip 2024 · 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.
Important: The Good Faith Estimate form is available for all subscription tiers. However, only team members with billing access for the client are able to create and send this form. To generate a Good Faith Estimate for a specific client: Navigate to the client’s Overview page; Click New > Good Faith Estimate
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage bo...
