Form CMS-10791 Good Faith Estimates Template and Instructions

OMB Control Number: 0938-1433
Expiration Date: 11/2025
Appendix 2
Standard Form: “Good Faith Estimate for Health Care Items and Services” Under the No
Surprises Act
(For use by health care providers, facilities, and providers of air ambulance services no later than
January 1, 2022)
Instructions
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care
providers, health care facilities, and providers of air ambulance services are required to provide a good
faith estimate of expected charges for items and services to individuals who are not enrolled in a group
health plan or group or individual health insurance coverage, or a Federal health care program, or a
Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals) or not
seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits
plan (self-pay individuals) in writing (and may also provide it orally, if an uninsured (or self-pay)
individual requests a good faith estimate in a method other than paper or electronically), upon request or
at the time of scheduling health care items and services. For ease of reference, for purposes of this
document, the term “provider” should be considered to include providers of air ambulance services.
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
and services must be furnished within 1 business day of scheduling an item or service to be provided in
at least 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 determine whether the circumstances require the
use of the standard good faith estimate form or permit use of the abbreviated (no cost) good faith
estimate form, then fill in the blanks with the appropriate information on the appropriate form. 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, a good faith
estimate that meets all of the requirements under 45 CFR 149.610, is necessary in order 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, including the HHS
interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October
7, 2021 (86 FR 55980).
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 0938-1433. 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
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.

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[NAME OF CONVENING PROVIDER OR CONVENING FACILITY]

Good Faith Estimate for Health Care Items and Services
Patient
Patient First Name

Middle Name

Patient Date of Birth:

Last Name

/

/

Account Number (last four digits)
(optional):
Patient Mailing Address, Phone Number, and Email Address
Street or PO Box

Apartment

City

State

ZIP Code

Phone
Email Address
Patient’s Contact Preference:

[ ] By mail

[ ] By email

[ ] By phone

Patient Diagnosis (if determined)
Primary Service or Item Requested/Scheduled

Patient Primary Diagnosis

Primary Diagnosis Code

Patient Secondary Diagnosis

Secondary Diagnosis Code

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

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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[S] OF SERVICE, IF SCHEDULED] [[ADD
IF ADDITIONAL ITEMS/SERVICES ARE BEING INCLUDED], as well as for
items or services reasonably expected to be furnished in conjunction with the
primary item or service as part of the period of care]. [Include if items or services
are reoccurring, “The estimated costs are valid for 12 months from the date of the
Good Faith Estimate.”]

4

[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
[Street, City, State, ZIP]

Diagnosis Code (if
required for the
calculation of the
GFE)
[ICD code]

Service/Procedure
Code

Quantity

Expected Cost

[Service/Procedure Code
Type: Service/Procedure
Code Number]

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

5

[Provider/Facility 2] Estimate [Delete if not needed]
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

Phone

ZIP Code

Email

National Provider Identifier

Taxpayer Identification Number

Details of Services and Items for [Provider/Facility 2]
Service/Item

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

Diagnosis Code
(if required for
the calculation of
the GFE)
[ICD code]

Service/Procedure
Code

Quantity

Expected Cost

[Service/Procedure Code
Type: Service/Procedure
Code Number]

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

6

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

Provider/Facility Type

Street Address
City

State

Contact Person

Phone

ZIP Code

Email

National Provider Identifier

Taxpayer Identification Number

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

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

Diagnosis Code
(if required for the
calculation of the
GFE)
[ICD code]

Service/Procedure
Code

Quantity Expected Cost

[Service/Procedure Code
Type: Service/Procedure
Code Number]

Total Expected Charges from [ Provider / Facility 3] $
Additional Health Care Provider/Facility Notes

Total estimated cost for all services and items: $
7

Health Care Items/Services Expected to Be Separately Scheduled with Another
Provider or Facility
DISCLAIMER: For health care items/services listed below, separate good faith estimates will be
issued upon scheduling or upon request. Specific information such as the names and identifiers
for the providers or facilities that may furnish the services, diagnosis codes (if required for the
calculation of the GFE), service codes, and expected charges will be provided in separate good
faith estimates once these items or services are scheduled (or upon request).
Service/Item

Provider/Facility [Instructions for obtaining a good faith
estimate for the service/item, such as provider/facility
name, address, phone number, and email]

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Disclaimer

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,
and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider
or facility, federal law allows you to dispute the bill.
The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to
obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

If you are billed for more than this Good Faith Estimate, you may 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.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into
collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has
to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on
unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility
cannot take or threaten to take any retributive action against you for disputing your bill.

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There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing
your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the
$25 fee. If the SDR entity 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/consumers or call 1800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process,
visit www.cms.gov/nosurprises/consumers, email [email protected], or call 1-800985-3059.

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.
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation
under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division
BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your
request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether
any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information
may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR
program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary.
But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor
of the provider or facility.

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Abbreviated GFE for No-Cost Health Care Items or Services
This abbreviated GFE should only be used by a provider or facility that does not expect to bill
the uninsured (or self-pay) individual for items or services furnished on the date the items or
services are expected to be provided.

[insert NAME OF PROVIDER OR FACILITY]

Good Faith Estimate for No-Cost Health Care Items & Services
This provider/facility will not bill you for items or services scheduled to
be provided on [insert date(s)]
[If items or services have not been scheduled, replace with this: This
provider/facility will not bill you for items or services.]
Patient Name:

Patient Date of Birth:

Patient Identifier (optional):
Provider/Facility Name:
Provider/Facility Street Address (where items or services are expected to be furnished):
City:
Provider/Facility Contact:

State:

ZIP Code:

Phone:

Email Address:
National Provider Identifier (NPI):

Taxpayer Identification Number (TIN):

Date of Good Faith Estimate:
Disclaimer
The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to
obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.
There may be additional items or services the convening provider or convening facility recommends as
part of the course of care that must be scheduled or requested separately.
If you are billed for more than this Good Faith Estimate, you may 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.

If you do receive a bill that is $400 or more, 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. The initiation of this process will not adversely affect the quality of health care services furnished to
an uninsured (or self-pay) individual by a provider or facility.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into
collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has
to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on
unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility
cannot take or threaten to take any retributive action against you for disputing your bill.
For questions or more information about your right to a Good Faith Estimate, the dispute resolution
process, or to get a form to start the dispute resolution process, visit
www.cms.gov/nosurprises/consumers, email [email protected], or call 1-800-9853059.

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 by the provider or
facility.
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any
supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section
112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L.
116-260). We need the information on the form to process your request to initiate a payment dispute,
verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of
interest exists with the independent dispute resolution entity selected to decide your dispute. The
information may also be used to: (1) support a decision on your dispute; (2) support the ongoing
operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with
program rules. Providing the requested information is voluntary. But failing to provide it may delay or
prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or
facility.