Good Faith Estimate Template for Therapists (No Surprises Act)

What Is the Good Faith Estimate?

The Good Faith Estimate (GFE) is a written estimate of expected charges for healthcare services, required under the No Surprises Act (Public Law 116-260), which took effect on January 1, 2022. The law was designed to protect patients from unexpected medical bills, and it applies to all healthcare providers — including mental health professionals in private practice.

For therapists, the GFE means that every uninsured or self-pay client must receive a clear, written estimate of how much their treatment is expected to cost before services begin.

When You Need It

• Before the first session with any self-pay or uninsured client
• When an existing client transitions from insurance to self-pay
• When the expected course of treatment changes significantly (e.g., increasing from weekly to twice-weekly sessions, adding a new service like psychological testing)
• When a client requests a GFE, regardless of whether they have scheduled services
• When updating a GFE that is no longer accurate due to changes in treatment plan, fees, or expected duration

Who Qualifies as "Self-Pay or Uninsured"

The No Surprises Act defines the GFE obligation broadly. You must provide a GFE to:

• Clients who have no health insurance
• Clients who have insurance but choose not to use it for your services (common in therapy, where clients prefer privacy or their plan does not cover your services)
• Clients using Employee Assistance Programs (EAPs) after their EAP sessions are exhausted, if they transition to self-pay
• Clients whose insurance does not cover mental health services or who have out-of-network benefits they choose not to use

If a client uses insurance for your services, the GFE requirement does not currently apply to you for that client, though the insurer has separate obligations.

What Must Be Included in a Good Faith Estimate

The GFE must contain specific elements as defined by CMS regulations:

Required Elements

1. Client's name and date of birth
2. Description of the primary service — including the healthcare service or item being provided
3. Itemized list of expected services — each service listed separately with its corresponding CPT code (or HCPCS code) and ICD-10 diagnosis code
4. Expected charges for each service — your standard fee for each service listed
5. Provider information — name, NPI number, TIN (Tax Identification Number), and contact information
6. Date of service or expected service period — for recurring services like therapy, this is typically a date range
7. Disclaimer language — required notices about the client's right to dispute charges that exceed the GFE by $400 or more

Common CPT Codes for Therapy

CPT Code	Description	Typical Duration
90791	Psychiatric diagnostic evaluation	45-90 min
90834	Individual psychotherapy	38-52 min
90837	Individual psychotherapy	53+ min
90847	Family/couples therapy (client present)	50 min
90846	Family therapy (client not present)	50 min
90853	Group psychotherapy	45-90 min
90785	Interactive complexity add-on	N/A
96130	Psychological testing evaluation	60 min
96131	Psychological testing evaluation, each additional hour	60 min

Complete Good Faith Estimate Template

How to Provide a Good Faith Estimate Step by Step

Step 1: Identify whether the client is self-pay or uninsured. During your initial contact or intake process, ask about insurance status. If the client does not have insurance or chooses not to use it, you are required to provide a GFE. Many therapists add this question to their intake paperwork or scheduling form.

Step 2: Determine expected services and duration. Based on the client's presenting concerns (as described during the initial phone consultation or intake), estimate the type and frequency of services you expect to provide over a 12-month period. This requires clinical judgment — you do not need to predict the future perfectly, but you do need to provide a reasonable estimate.

Step 3: Calculate expected costs. Multiply the expected number of sessions by your fee for each service type. Include the initial evaluation and any other services you reasonably expect to provide (e.g., psychological testing, family sessions, crisis management).

Step 4: Complete the GFE with all required elements. Use the template above or your EHR's built-in GFE form. Ensure you include all required elements: provider information with NPI and TIN, client information, diagnosis codes, CPT codes, itemized costs, and the required disclaimer language.

Step 5: Provide the GFE to the client within the required timeframe. If the client scheduled 3+ business days in advance, provide the GFE within 1 business day of scheduling. If scheduled 10+ business days in advance, provide within 3 business days. You can deliver the GFE electronically (with client consent) or on paper.

Step 6: Obtain the client's acknowledgment. Have the client sign or electronically acknowledge receipt of the GFE. While a signature is not explicitly required by the regulation, it documents that the client received the estimate.

Step 7: Retain a copy in the client's file. Keep the signed GFE in the client's clinical record for at least as long as your state's record retention requirements mandate.

Step 8: Update the GFE when treatment changes. If the expected course of treatment changes — for example, the client needs more frequent sessions, you add a new service, or you raise your fees — provide an updated GFE. This protects you from a dispute if charges exceed the original estimate by $400 or more.

Common Mistakes

1. Failing to provide a GFE at all. Many therapists in private practice are still unaware of or non-compliant with the No Surprises Act. This is a federal requirement with potential penalties, and it applies to every licensed mental health professional seeing self-pay clients — not just physicians or hospitals.

2. Providing the GFE after the first session instead of before. The law requires the estimate before services are delivered. Handing a client a GFE at the end of the first session does not satisfy the requirement. Build the GFE into your pre-appointment intake workflow.

3. Omitting the required disclaimer language. The GFE must include the specific notice about the client's right to dispute bills exceeding the estimate by $400 or more. Leaving this out makes your GFE non-compliant, even if all other elements are present.

4. Underestimating costs to make therapy seem more affordable. If your actual charges consistently exceed your GFEs, you expose yourself to dispute resolution proceedings. Provide honest estimates based on reasonable clinical expectations. It is better to slightly overestimate and have clients pay less than expected.

5. Using a diagnosis code before completing a diagnostic evaluation. If you have not yet evaluated the client, you can list the expected diagnosis as "To be determined upon evaluation" or use the reason-for-visit code. Do not assign a diagnosis code on a GFE before you have conducted an assessment — this creates a documentation inconsistency.

6. Forgetting to update the GFE when treatment changes. A GFE from intake that estimates weekly sessions for 6 months is no longer valid if the client is now attending twice-weekly sessions and has added couples therapy. Issue a new GFE whenever the scope of treatment changes materially.