Good Faith Estimate Form For Therapists [Free Downloadable Template]

The good faith estimate is a notification of expected charges for a scheduled or requested service (or item). The “expected charge” for an item or service is either:

  • The cash pay rate or rate established by a provider for an uninsured (or self-pay) patient, reflecting any discounts for such individuals; or
  • The amount the provider would expect to charge if the provider intended to bill a health care plan directly for such item or service.

Provide transparent and fair estimates for your services: Psychologists and other mental health care providers are now (as of January 1, 2022) required by law to give uninsured and self-pay patients a good faith estimate of the costs for services.

In July, 2021, the U.S. Departments of Health and Human Services, Labor, and the Treasury (the Departments) released the “Requirements Related to Surprise Billing; Part I,” to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.

But, many mental health providers have been left confused, and without resources when it comes to providing their patients with a disclosure form, they’re now required by law to provide. So, we here at Belongly have created a simple and easy-to-use form that you can print, fill out and provide to your clients upon request.

Download your free copy of the good faith estimate form. (PDF or Word doc)

Share a few details, and we’ll take you to a page where you can download this full-color, interactive PDF map.