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The No Surprises Act and Good Faith Estimates

The No Surprises Act and Good Faith Estimates

Important: The information below is specific to using the No Surprises Act Good Faith Estimate & Consent Disclaimer for Health Care Goods and Services template within SimplePractice. It’s the responsibility of each respective provider to ensure their Good Faith Estimates and Consent Disclaimers are in compliance with local, state, and federal guidelines.

The No Surprises Act, also known as No Surprise Billing, went into effect on January 1, 2022. This act is part of a legislative package that was passed in December 2020. This guide is a resource for answering your questions regarding this legislation.

In this guide, we’ll cover:

No Surprises Act overview

The No Surprises Act, which is part of the Consolidated Appropriations Act of 2021, is designed to protect clients from receiving unexpected medical bills. The Good Faith Estimate provision of the No Surprises Act is designed to give clients an estimate of how much they’ll be charged for the healthcare services they’ll be receiving, prior to their appointment.

Requirements for providers

As of January 1, 2022, this legislation applies to all healthcare providers and facilities operating under the scope of a state-issued license or certification. You’re required to share a specific consent document in addition to a Good Faith Billing Estimate, prior to beginning care.

State-licensed or certified healthcare providers are required to provide a Good Faith Estimate of charges to every new and continuing client who’s either uninsured or isn’t planning to submit a claim to their insurance for the services they’re seeking. You’re also required to inform every uninsured or self-pay client of their right to receive a Good Faith Estimate.

We recommend asking each client whether they have insurance and intend to use it to cover the services that they seek. If the answer to either question is no, they’ll need a Good Faith Estimate prior to their appointment.

Providers are also required to highlight the No Surprises Act on their Professional Website. A link to more information about the No Surprises Act must be present, along with a statement informing clients that they’re entitled to a Good Faith Estimate. To do this, see Making sure your Professional Website is compliant.

Creating a Good Faith Estimate for a client

Important: The Good Faith Estimate form is available for all subscription tiers. However, only team members with billing access for the client are able to create and send this form.

To generate a Good Faith Estimate for a specific client:

  • Navigate to the client’s Overview page
  • Click New > Good Faith Estimate


Note: Good Faith Estimate forms can only be created on the SimplePractice web app.

  • Fill out the form
    • Manually update the date range for the estimated services and the number of services you estimate to provide
    • You can click + Add service to add other services
    • Use the Notes field to add any additional comments


  • Click Save
  • Review the document 
    • To edit, click the pen icon
    • To print, click the printer icon
    • To download, click the arrow icon
    • To share with the client for eSignature, click Share


Once you send the Good Faith Estimate to a client, you can edit it or retract it from the Files tab. To do so:

  • Navigate to the client's Overview page
  • Select the Files tab
  • Click the three dots to the right of the Good Faith Estimate
  • Select Delete
    • This will make the document editable again


Note: The X will only appear next to the document if it’s in the Sent or Viewed status.

If the client has already signed the Good Faith Estimate, the document becomes locked. If you’d like to edit it, you’ll want to create a new Good Faith Estimate for the client. There isn’t a way to delete a locked Good Faith Estimate on a client’s chart.

Note: If you prefer to use the template, Good Faith Estimate for Health Care Items and Services, you can find that in the Other documents section of our Template Library. You can also find a PDF version under Forms at the bottom of this guide.

Additional resources


Are client signatures required on the consent document or the Good Faith Estimate?

Both the consent document and the Good Faith Estimate aim to protect clients by educating them about the differences between in-network and out-of-network coverage. A signature on either document consents to the following:

  • I’m giving up some consumer billing protections under federal law.
  • I may get a bill for the full charges for these items and services, or have to pay out-of-network cost-sharing under my health plan.
  • I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.

Client signatures aren’t required on either the consent document or the Good Faith Estimate. However, if the client chooses not to sign, the provider can opt out of providing care and the client can proceed to find an in-network provider instead.

Is there a way to be reminded of when it’s time to update a Good Faith Estimate or when the amount estimated has been reached?

A reminder will appear on the Reminders page 30 days before each Good Faith Estimate’s expiration date. This will list the client’s name and the date that the Good Faith Estimate will expire. To review the Good Faith Estimate in question, click Review.

Note: To learn more about the Reminders page, see Using practice reminders.

We don’t currently have a reminder for when the amount estimated has been reached. Our Product team is continuing to evaluate ways to make it easier for our customers to comply with this legislation.

In the meantime, we recommend commenting and/or voting on the related feature enhancements below on our Ideas and Suggestions board. That way, you’re notified via email if these feature enhancements are released.

Will the Good Faith Estimate for Health Care Items and Services template be made available for customers on the Starter plan?

Customers on the Starter plan don’t have access to Other document templates. At this time, there aren’t plans to enable customers on the Starter plan to access the Good Faith Estimates For Health Care Items and Services template.

That said, all of our customers can create Good Faith Estimates directly from a client’s Overview page. You can learn more by following the steps in our Creating a Good Faith Estimate for a client section.

Alternatively, our customers can download these documents from or from the Forms section of this Help Center guide. These documents can still be uploaded to a client’s profile and shared with them via the Client Portal. To do this, see Uploading and sharing documents for individual clients.

Why can’t I create an intake form to share with clients so they can easily sign the Good Faith Estimate?

It's important to note that the Good Faith Estimates shouldn’t be an intake form because they include client-specific information, such as their name, date of birth, and diagnosis, prior to the client completing the document. In order to accomplish this using an intake form, you'd have to include PHI on an intake form template, which we don’t recommend as it could potentially be shared with other clients in your account.

How do I remove a diagnosis from the Good Faith Estimate?

A diagnosis is required on the Good Faith Estimate once it’s saved to the client’s Overview page. There isn’t a way to remove it from this document.

How do I change the disclaimer text on the Good Faith Estimate?

The text within the disclaimer/consent form is required on the Good Faith Estimate. There isn’t a way to update it.

Is there a way to create a single Good Faith Estimate for a family?

Like all other client documents, a Good Faith Estimate is for one specific client. There isn’t a way to create a Good Faith Estimate for a family if you see multiple members.

Are client email addresses required on the Good Faith Estimate?

While client email addresses, physical addresses, and phone numbers aren't required on the Good Faith Estimate, client names and birthdates are required. See additional information from The No Surprises Act’s Good Faith Estimates and Patient-Provider Dispute Resolution Requirements.

What if my TIN is my SSN? Is my TIN required on the Good Faith Estimate?

Yes, per, your TIN is required on the Good Faith Estimate. If your TIN is your SSN, we recommend reaching out to your legal advisor(s) for advice on how to fill out this form.

If I’m creating a Good Faith Estimate for a client before assigning a diagnosis, what should I do?

If a diagnosis hasn’t yet been assigned to the client, you can use the drop down menu under Diagnosis code to initially select None.


Once a diagnosis has been assigned, the Good Faith Estimate can be recreated to include the updated diagnosis code.

Does the Good Faith Estimate include all legally required information and disclaimers?

The Good Faith Estimate form includes all the necessary information required on the form as provided by The disclaimers and information about the form populates when the client views the form in the Client Portal:


This information doesn’t appear when creating a new Good Faith Estimate form on the client’s Overview page. To view the required information and disclaimers, we recommend creating a Good Faith Estimate for the Jamie Appleseed demo client to view the form from the client’s perspective in the Client Portal.

What is the default text of the Good Faith Estimate disclaimer?

Here’s the default text of the Good Faith Estimate disclaimer that clients see in the Client Portal before signing it. This text is unable to be edited or customized.

OMB control number: 0938-XXXX

Expiration Date: MONTH DAY, YEAR

Surprise Billing Protection form

This document describes your protections against unexpected medical bills. It also asks if you'd like to give up those protections and pay more for out-of-network care.

IMPORTANT: You aren't required to sign this form and shouldn't sign it if you didn't have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan's network, which may cost you less.

If you'd like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.

You're getting this notice because this provider or facility isn't in your health plan's network and is considered out-of-network. This means the provider or facility doesn't have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more.

If your plan covers the item or service you're getting, federal law protects you from higher bills when:

  • You're getting emergency care from an out-of-network provider or facility, or
  • An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.

Ask your health care provider or patient advocate if you're not sure if these protections apply to you.

If you sign this form, be aware that you may pay more because:

  • You're giving up your legal protections from higher bills.
  • You may owe the full costs billed for the items and services you get.
  • Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn't one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.

See the next page for your cost estimate.

Can I update the expiration date on the Good Faith Estimate?

After generating a Good Faith Estimate form, the expiration date will automatically be set to one year from the date the form was created. You can edit the expiration date to be within one year of the date that’s listed in the Date provided field.

To edit the expiration date:

  • Navigate to the client’s Overview page
  • Open the Good Faith Estimate form
  • Select the pen icon


  • In the Expiration date field, enter the new date
    • The expiration date must be within 1 year of the date provided


  • Click Save

How do I update the OMB control number?

The OMB control number is required on the Good Faith Estimate and will appear in the top right corner of the downloaded version of the form.


Note: The OMB control number isn’t visible when creating or editing a form. It’ll only appear when viewing a downloaded version.

The OMB control number isn’t editable and will be the same for all Good Faith Estimates.

Can I still use the Good Faith Estimate template?

If you prefer to use our Good Faith Estimate for Health Care Items and Services template, you can find it in our Template Library. This template can be edited and customized, if needed. To learn more, see Adding an other document to a client's chart.

Note: The Good Faith Estimate for Health Care Items and Services template won’t automatically populate with your provider information or client information.

Can I add a suffix to my name in the Provider section?

Yes, you can update your name to include a suffix. To do so:

  • Navigate to Settings > Profile & Security
  • Under SimplePractice profile, click Edit
  • Enter your suffix in the Suffix field


  • Click Save

Anything entered in the field will appear in the Provider section of your clients’ Good Faith Estimates.


Can I create a Good Faith Estimate for a client using the SimplePractice mobile app?

No, there isn’t a way to create a Good Faith Estimate using the SimplePractice mobile app. Good Faith Estimates can only be created for a client on the SimplePractice web app.


You can find a PDF version of both the consent document and the Good Faith Estimate from below:


Still have questions?

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