Good Faith Estimate checklist

A session-only checklist for confirming all required Good Faith Estimate elements before furnishing scheduled services to self-pay patients.

Updated July 20, 2026

Use this session-only checklist to confirm all NSA-required Good Faith Estimate (GFE) elements before furnishing scheduled services to uninsured or self-pay patients. The applicable NSA requirements and timeframes remain the controlling sources.

Progress

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Confirm the patient is uninsured or self-payGFE requirements apply to individuals without insurance coverage and to those who indicate they will not bill a plan for the service.Verify the scheduled service detailsConfirm the service(s) scheduled, including the date, the primary item or service, and any expected co-provider or facility involved.Include all expected billing codesList the expected CPT, HCPCS, or DRG codes for the primary service and any items or services reasonably expected to be furnished.Include the expected diagnosis codesProvide the expected ICD-10 diagnosis code(s) supporting the scheduled service where applicable.List the expected charges for each item or serviceInclude the expected charge amount for each billing code; indicate whether items are bundled or billed separately.Include the facility or provider NPI and contact detailsIdentify the furnishing provider or facility by name, NPI, and a contact for scheduling or estimate questions.Provide the GFE within the required timeframeFor scheduled services, issue the GFE within the NSA timeframe based on when the service was scheduled; verify the applicable window before furnishing the service.Retain GFE documentation and any updatesKeep a copy of the furnished estimate and any subsequent updates in the secured system as evidence of compliance with the NSA requirement.

Use this checklist safely

This tool does not provide legal advice and stores no selections. Verify current NSA requirements and timeframes.

Related Knowledge

Good Faith Estimates for Self-Pay Patients
Required GFE elements, timeframes, and patient rights under the NSA.
What Is the No Surprises Act?

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