A Good Faith Estimate Template for Cash-Pay Psychiatry

Every patient in a cash-pay psychiatric practice is legally owed a Good Faith Estimate: a written, itemized preview of expected charges, required by the No Surprises Act for care furnished since January 1, 2022. The rule's definition of "self-pay" covers patients who have insurance but don't run claims through it, which in a cash practice describes your entire panel. The estimate is due within 1 to 3 business days of scheduling depending on lead time, must carry your NPI, TIN, expected service codes, and expected charges, and a single estimate can cover up to 12 months of recurring visits. The template below is pre-built for a psychiatric intake plus a year of monthly follow-ups.

This is practice-operations guidance and not legal advice. Have your attorney look over your final form, and involve them before you respond to any formal billing dispute.

Does a cash-pay practice owe every patient an estimate?

Yes. 45 CFR 149.610 defines an "uninsured (or self-pay) individual" two ways: someone with no applicable coverage at all, and someone who has coverage but does not seek to have a claim submitted to it. A patient with excellent commercial insurance who pays your posted fee sits squarely in the second bucket, so a practice that files no claims owes an estimate to 100 percent of its panel. Issue one to superbill patients too: the rule's insured-patient phase, which ties estimates to Advanced Explanations of Benefits from health plans, still has no implementation date, and once your form is built the marginal cost of sending it is zero.

Medicaid enrollees raise a different question before this one, whether your state lets them pay you cash at all. That answer has its own post on seeing Medicaid patients in a cash-pay practice.

1. Post the required notice before anyone asks

The regulation makes you advertise the estimate's availability, and it prescribes where: prominently on your website, in your office, and on-site where scheduling happens, plus an oral mention when patients schedule, in accessible formats and the languages your patients speak. CMS publishes a model notice in its No Surprises Act rules and fact sheets; adapting it takes minutes. In practice this means one standing paragraph on your website's fees page, the same paragraph in your intake packet, and one line in your scheduling script or booking confirmation.

2. Send it inside the deadline window

The deadline depends on how far out the visit is booked, and the shortest window is one business day:

Two wrinkles. A visit booked less than 3 business days ahead triggers no scheduling deadline under the rule, though a request still starts the 3-day clock, and sending one anyway costs nothing. And prospective patients who merely ask about costs are entitled to an estimate before ever booking. The clean operational answer to all of it is to attach the estimate to your booking confirmation, so the tightest deadline is met the moment the appointment exists. If your EHR can generate the estimate from your fee schedule at booking, turn that on; if it can't, a saved template plus a two-minute fill beats tracking business-day math patient by patient.

3. Build the estimate from your fee schedule

The required contents are spelled out in the regulation, and none of them are hard for a solo practice. Your estimate must include:

• Patient name and date of birth
• A plain-language description of the primary service, with its date if scheduled
• An itemized list of expected services with applicable diagnosis codes, expected service codes, and expected charges
• Your name, NPI, and TIN, plus the state(s) you're licensed in and the location where care is provided
• The required disclaimers: this is an estimate only, actual charges may differ, additional services may be recommended, the patient can dispute a bill substantially above the estimate, and the estimate is not a contract

The diagnosis code trips up psychiatric intakes, since new patients don't have one yet. CMS guidance resolves it: a diagnosis code isn't required when no diagnosis has been determined, so "TBD" is acceptable for an initial evaluation, updated on later estimates. The charges themselves come straight from your fee schedule. List the services you reasonably expect to furnish; conditional fees like paperwork, letters, and prior auths belong on your published fee schedule rather than the estimate, and how to set those is covered in charging for calls, emails, and paperwork.

4. Adapt this template

Fill the brackets from your own fee schedule, deliver it on paper or electronically per the patient's preference (electronic copies must be saveable and printable), and keep a copy.

GOOD FAITH ESTIMATE OF EXPECTED CHARGES
(Provided under the No Surprises Act, 45 CFR 149.610)

Date of estimate: [DATE]
Patient name: [PATIENT NAME]        Date of birth: [DOB]

Provider: [YOUR NAME], [CREDENTIALS]
Practice: [PRACTICE NAME]
NPI: [NPI]        TIN: [TIN]
Licensed in: [STATE(S)]        Service location: [ADDRESS or "Telehealth"]
Contact: [PHONE / EMAIL]

ESTIMATED SERVICES AND CHARGES

Initial visit
  Service: Psychiatric diagnostic evaluation
  Service code: [90792]        Diagnosis code: TBD (no diagnosis has been
    established yet; this will be updated on future estimates)
  Scheduled date: [DATE, if scheduled]
  Expected charge: $[INTAKE FEE]

Follow-up care (recurring, if treatment continues)
  Service: Medication management follow-up [with psychotherapy add-on]
  Service code(s): [99213 or 99214] [+ 90833]        Diagnosis code: TBD
  Expected frequency: [e.g., monthly during medication adjustment, then
    every 2-3 months as clinically appropriate]
  Expected number of visits over the next 12 months: up to [N]
  Expected charge per visit: $[FOLLOW-UP FEE]

Total estimated charges over the next 12 months: $[LOW] to $[HIGH],
depending on visit frequency.

This estimate covers services furnished by the practice listed above. If
you are referred to other providers or facilities (for example, labs or
a therapist), each is responsible for its own estimate.

DISCLAIMERS
- This Good Faith Estimate shows the cost of items and services that are
  reasonably expected for your health care needs, based on information
  known when the estimate was created.
- This is an estimate only. Actual items, services, and charges may
  differ. Your treatment plan may change after your evaluation, and
  additional items or services may be recommended that are not
  reflected here.
- If you are billed at least $400 more than this estimate, you have the
  right to dispute the bill through the federal patient-provider dispute
  resolution process, generally within 120 days of receiving the bill.
  Information: www.cms.gov/nosurprises
- This Good Faith Estimate is not a contract and does not require you to
  obtain services from the provider listed above.
- Keep a copy of this estimate in a safe place.

This estimate applies to services within 12 months of the date above. A
new estimate will be issued if your care continues past that point or if
fees change.

5. Cover the year, then reissue

One estimate can cover recurring care for up to 12 months, which is what makes this workable for monthly med management. The estimate must state the expected scope of the recurring service: frequency, timeframe, and total expected number of visits. Past 12 months, a new estimate is required, and if anything material changes sooner (a fee increase, a shift from monthly to quarterly visits, a new expected service), issue a corrected estimate before the change takes effect. Two calendar rules handle it: reissue at every fee change, and reissue at the annual mark (many practices pair it with the yearly intake-paperwork refresh). Estimates must also be kept the way you keep the chart itself; the American Psychological Association's NSA FAQ reads the rule as requiring retention for at least 6 years, or longer where state record-retention law demands it.

What happens if your bill runs past the estimate?

A patient billed at least $400 above your estimate can take you to the federal patient-provider dispute resolution process. As of August 2026, the patient files within 120 days of the bill, pays a $25 administrative fee, and a third-party reviewer decides what the patient actually owes; while the dispute is pending you cannot send the bill to collections, and if the patient prevails, their payment is reduced by that fee. For a psychiatric practice with published fees and an annual recurring estimate, staying under the threshold is almost automatic, which is exactly the point.

"Treat the $400 threshold as the real compliance line," says David Cohen, CPA, JD, who reviewed this article. "If every bill you send stays within $400 of the estimate on file, the GFE remains a disclosure document. The providers who should worry are the ones billing for services they never estimated."

What is the actual penalty for skipping estimates?

The No Surprises Act carries a statutory ceiling of $10,000 in civil monetary penalties per violation, and that number describes the law as a whole; no GFE-specific fine is on public record. Enforcement runs primarily through the states, with HHS as backstop, and in practice it has run through the dispute process above rather than through fines. The rule itself is still being revisited: WEDI's provider survey results, published July 28, 2026 from 38 provider responses collected in early 2026, are feeding the agencies' work on the still-unimplemented insured-patient phase. The realistic exposure today is a lost dispute capping what you can collect, a state complaint, and the awkwardness of explaining to a board or payer auditor why a federally required document is missing from every chart. Since compliance costs one template and one workflow tweak, take the cheap insurance.

The compliance checklist

• Notice posted on your website, in the office, and in the scheduling script
• Template saved with your NPI, TIN, license state(s), codes, and current fees
• Estimate goes out with the booking confirmation, covering the 1-business-day deadline
• Prospective patients who ask about cost get an estimate within 3 business days
• New patients: diagnosis code marked TBD until an evaluation establishes one
• Recurring estimate states frequency and visit count, capped at 12 months
• Reissue on every fee change and at the 12-month mark
• Copy retained like the chart, 6 years minimum
• Every bill stays within $400 of the estimate on file