CMS-10791 Good Faith Estimate for Health Care Items and Services

Appendix 2

OMB Control Number [XXXX-XXXX]
Expiration Date [MM/DD/YYYY]

Standard Form: “Good Faith Estimate for Health Care Items and Services” Under the No
Surprises Act
(For use by health care providers no later than January 1, 2022)
Instructions
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 both orally and in writing, upon request or at the time of scheduling
health care items and services.
This form may be used by the health care providers to inform individuals who are not enrolled in a plan
or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled
but not seeking to file a claim with their plan or coverage (self-pay individuals) of the expected charges
they may be billed 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 and services must
be furnished within 1 business day of scheduling an item or service to be provided in 3 business days;
and within 3 business days of scheduling an item or service to be provided in at least 10 business days.
To use this model notice, the provider or facility must fill in the blanks with the appropriate information.
HHS considers use of the model notice to be good faith compliance with the good faith estimate
requirements to inform an individual of expected charges. Use of this model notice is not required and
is provided as a means of facilitating compliance with the applicable notice requirements. However,
some form of notice, including the provision of certain required information, is necessary to begin the
patient-provider dispute resolution process.
NOTE: The information provided in these instructions is intended only to be a general informal
summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or
formal policy guidance upon which it is based. Readers should refer to the applicable statutes,
regulations, and other interpretive materials for complete and current information. [Link to IFR when
available.]
Health care providers and facilities should not include these instructions with the documents given
to patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid Office of Management and Budget (OMB) control number. The
valid OMB control number for this information collection is 0938-XXXX. The time required to
complete this information collection is estimated to average 1.3 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or

OMB Control Number [XXXX-XXXX]
Expiration Date [MM/DD/YYYY]

suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

[NAME OF CONVENING PROVIDER OR CONVENING FACILITY]

Good Faith Estimate for Health Care Items and Services
Patient
Patient First Name
Patient Date of Birth:

Middle Name

Last Name

____________/________/__________

Patient Identification Number:
Patient Mailing Address, Phone Number, and Email Address
Street or PO Box
City

Apartment
State

ZIP Code

Phone
Email Address
Patient’s Contact Preference:

[ ] By mail

[ ] By email

Patient Diagnosis
Primary Service or Item Requested/Scheduled
Patient Primary Diagnosis

Primary Diagnosis Code

Patient Secondary Diagnosis

Secondary Diagnosis Code

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OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

If scheduled, list the date(s) the Primary Service or Item will be provided:
[ ] Check this box if this service or item is not yet scheduled
Date of Good Faith Estimate:

____________/________/__________

Summary of Expected Charges
(See the itemized estimate attached for more detail.)
Provider Name

Estimated Total Cost

Provider Name

Estimated Total Cost

Provider Name

Estimated Total Cost

Total Estimated Cost: $
The following is a detailed list of expected charges for [LIST PRIMARY SERVICE
OR ITEM], scheduled for [LIST DATE OF SERVICE, IF SCHEDULED]. [Include if
items or services are reoccurring, “The estimated costs are valid for 12 months
from the date of the Good Faith Estimate.”]

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OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

[Provider/Facility 1] Estimate
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

Phone

National Provider Identifier

ZIP Code
Email
Taxpayer Identification Number

Details of Services and Items for [Provider/Facility 1]
Service/Item

Address where service/item
will be provided

Diagnosis Code

Service Code

[Street, City, State, ZIP]

[ICD code]

[Service Code
Type: Service
Code Number]

Quantity

Expected Cost

Total Expected Charges from [Provider/Facility 1] $
Additional Health Care Provider/Facility Notes

4

OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

ZIP Code

Phone

National Provider Identifier

Email
Taxpayer Identification Number

[Provider/Facility 2] Estimate [Delete if not needed]
Details of Services and Items for [Provider/Facility 2]
Service/Item

Address where service/item
will be provided
[Street, City, State, ZIP]

Diagnosis Code

Service Code

[ICD code]

[Service Code
Type: Service
Code Number]

Quantity

Expected Cost

5

OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

Total Expected Charges from [Provider/Facility 2] $
Additional Health Care Provider/Facility Notes

6

OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

[Provider/Facility 3] Estimate [Delete if not needed]
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

ZIP Code

Phone

National Provider Identifier

Email
Taxpayer Identification Number

Details of Services and Items for [Provider/Facility 3]
Service/Item

Address where service/item
will be provided

Diagnosis Code

Service Code

[Street, City, State, ZIP]

[ICD code]

[Service Code
Type: Service
Code Number]

Quantity

Expected Cost

Total Expected Charges from [Provider/Facility 3]$
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OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

Additional Health Care Provider/Facility Notes

Total estimated cost for all services and items: $

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Disclaimer

OMB Control Number [XXXX-XXXX]
ExpirationDate [MM/DD/YYYY]

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. You could be charged more if complications or
special circumstances occur. If this happens, federal law allows you to dispute
(appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have
the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the
billed charges are higher than the Good Faith Estimate. You can ask them to
update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask
if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of
Health and Human Services (HHS). If you choose to use the dispute resolution
process, you must start the dispute process within 120 calendar days (about 4
months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your
dispute agrees with you, you will have to pay the price on this Good Faith
Estimate. If the agency disagrees with you and agrees with the health care
provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to
www.cms.gov/nosurprises or call [HHS PHONE NUMBER].
For questions or more information about your right to a Good Faith Estimate
or the dispute process, visit www.cms.gov/nosurprises or call [HHS NUMBER].

Keep a copy of this Good Faith Estimate in a safe place or take
pictures of it. You may need it if you are billed a higher amount.

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