Tip for Good Faith Estimate

You have the right to a Good Faith Estimate for ANY scheduled service if you are uninsured or self-pay

Tip for Good Faith Estimate

The GFE must include expected charges for the primary service and any reasonably expected related services

Tip for Good Faith Estimate

If your final bill exceeds the GFE by $400+, initiate a dispute within 120 days of the bill

Insurancemoderate

Good Faith Estimate of Expected Charges

Good Faith Estimate · Providers / Facilities (per No Surprises Act)

Estimate of expected charges for scheduled health care items and services. Under the No Surprises Act, providers must give uninsured or self-pay patients a good faith estimate before or at the time of scheduling.

Form Details

Total fields: 30
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Where to Submit This Form

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Provided to you by your healthcare provider

Providers must give you a Good Faith Estimate for scheduled services if you are uninsured or self-pay.

Filing Deadline

Providers must give you the GFE at least 1 business day before a scheduled service (3 business days if scheduled 3+ days in advance). You can also request one at any time.

Required Attachments

📎 No attachments required from you — the provider generates the GFE

Processing Time

Providers must provide the GFE within the required timeframes. If your actual bill exceeds the GFE by $400 or more, you can dispute it.

What Happens Next

Review the GFE carefully. If your final bill exceeds the GFE by $400 or more, you have the right to dispute the bill through the patient-provider dispute resolution process.

Tips for This Form

✓ You have the right to a Good Faith Estimate for ANY scheduled service if you are uninsured or self-pay
✓ The GFE must include expected charges for the primary service and any reasonably expected related services
✓ If your final bill exceeds the GFE by $400+, initiate a dispute within 120 days of the bill
✓ Request GFEs from multiple providers to compare prices for non-emergency services

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Providers / Facilities (per No Surprises Act) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.