Good Faith Estimates for Therapists: A Template and AI Checks

Give each self-pay client a written estimate of your expected charges: their details, the service and its codes, your fees by item, your identifiers, and the standard disclaimer. Send it within three business days of a request, sooner when booking is close. AI can check a draft against the field list, but only with the client's identity left out.

The rule comes from the No Surprises Act, and CMS publishes a model form. It applies to people who are uninsured and to people who have insurance but are not using it for this care, which covers every client who pays you privately. Most blank templates stop at "fill in the boxes". The harder part is the timing, the recurring-session wording, and noticing what you forgot, which is where a second pair of eyes, human or AI, earns its place.

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Who needs an estimate and when it is due

CMS's consumer pages say that, usually, a provider must give a good faith estimate to someone who is not using insurance to pay, when they schedule care at least three business days ahead or when they ask for one. You do not need to wait for the word "estimate": a client who asks "what will this cost?" in writing has asked for one, and CMS tells consumers they do not need to use the term "good faith".

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The model form's instructions set out the clock. An estimate must reach the client within three business days of a request. For care you schedule at least three business days in advance, it is due within one business day of scheduling. For care scheduled at least ten business days in advance, it is due within three business days of scheduling. Read that as: the further away the first session, the longer you have, but a request always starts a three-day clock.

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The last row is deliberately a question, not an answer. The form's instructions describe the "at least three business days" cases; they do not tell you what to do for a same-day crisis booking, and I would not invent a rule for it. Put the answer your adviser gives you into your booking script.

What the CMS form asks for, field by field

The model form is long because it also serves hospitals. A therapist with one clinician uses a fraction of it. Here is what a solo practice fills in, taken from the form's own headings.

• Patient block: first, middle and last name, date of birth, mailing address, phone, email, an optional last-four account number, and the client's contact preference (mail, email or phone).
• Primary service and diagnosis: the primary service requested or scheduled, and a primary and secondary diagnosis with codes "if determined". At intake you may not have one yet, so the field is conditional.
• Dates: the date or dates of the primary service if scheduled, or a tick that it is not yet scheduled, plus the date of the estimate itself.
• Summary of expected charges: a total per provider and an overall total.
• Provider details: name, type, address, contact person, National Provider Identifier and Taxpayer Identification Number.
• Itemised services: each service or item with the address where it is delivered, a diagnosis code if needed to calculate the estimate, a service or procedure code, a quantity and an expected cost.
• Recurring care line: for repeating services, the form's wording says the estimated costs are valid for 12 months from the date of the estimate.
• Disclaimer: that the estimate reflects what is known at the time, excludes unexpected costs, is not a contract, and that the client may be able to dispute a bill that is $400 or more above the estimate.

You can issue the estimate on your own paper. HHS says it treats use of the model notice as good-faith compliance, but the form states that use of it is not required. If you build your own, mirror the fields above rather than trimming for neatness: the form's instructions add that an estimate meeting all the regulatory requirements is what lets a client start the dispute process, so a missing field can matter later. Check you are using the current version of the CMS form, because the example PDF carries an expiry date on its control number; the copy linked from CMS's consumer pages, checked in November 2026, still showed an expiry of November 2025, so look for a newer version before you copy its layout.

A filled-in estimate for twelve weekly sessions

Here is an illustration for a solo therapist whose self-pay client has booked an intake and expects weekly sessions. The figures are invented for the example; use your own fee schedule and codes.

Below the table the estimate states that the figures cover 13 sessions across about three months, that the client may attend fewer or more, that late-cancellation fees under your published policy are separate and charged only if the client cancels late, and that the estimate is valid for 12 months from its date. Those sentences are what a generic template usually misses, and they are the ones a dispute turns on.

Note two choices. First, the service codes are the codes you would use for a claim, because the form asks for them; check them against the current code set each year, since descriptions and time ranges are revised. Second, the late-cancellation line is stated as a conditional, not folded into the total: the estimate lists what you reasonably expect, and you do not expect a cancellation. If you routinely charge a no-show fee, state its amount in the notes so the client has seen the number in writing.

Wording for the self-pay notes section

The "additional notes" box is where a therapy practice gets to say what is specific to therapy. Keep it short and factual. This is an illustrative wording you can adapt; have your adviser or professional body check it before use.

Notes
- This estimate covers an intake evaluation and 12 weekly individual sessions, delivered by [CLINICIAN NAME] at [ADDRESS] or by secure video.
- Telehealth sessions are charged at the same fee as in-person sessions.
- Fees for late cancellation (less than 24 hours) or missed sessions are [AMOUNT] each and are not included in the totals above.
- Letters, reports or phone calls outside session time are charged at [AMOUNT] per 15 minutes only if you request them.
- If your plan of care changes (for example, more frequent sessions), I will give you an updated estimate before the change.
- The estimated costs are valid for 12 months from the date of this estimate.

Notice what is not in there: no promise about how many sessions therapy will take, and no clinical language about the diagnosis. The estimate is a price document, not a treatment plan.

Where the AI check fits, and what must stay out of it

AI is good at one job here: comparing a finished draft against a checklist and saying what is missing. It is poor at knowing your fees, your codes or your state's rules, so it should never be the source of those. And a client's name, date of birth, address, diagnosis and appointment dates are protected health information. OpenAI's help centre says it does not offer a business associate agreement for ChatGPT Business, so identifiable estimates should not go into it. Its free ChatGPT for Clinicians workspace can sign an individual BAA, but the help page currently limits it to verified physicians, nurse practitioners, physician assistants and pharmacists, so most therapists cannot use that route. My method is to check the template and a placeholder version, then complete the real one in your practice system.

The prompt below works in any chat assistant. Replace the identifying fields with the placeholders shown and paste the rest.

You are checking a good faith estimate for self-pay therapy against a checklist. Do not invent fees, codes or legal rules. If you are unsure, say what the practice should confirm.

Checklist of required elements:
1. Patient name, date of birth, contact details and contact preference
2. Primary service requested or scheduled, and diagnosis with code if determined
3. Date of estimate and date(s) of service or a "not yet scheduled" tick
4. Provider name, address, contact person, NPI and TIN
5. Itemised services with codes, quantity and expected cost per item
6. Total expected charges per provider and overall
7. Recurring-care sentence (valid for 12 months) where care repeats
8. Disclaimer: not a contract, excludes unexpected costs, right to dispute a bill $400 or more above the estimate

Draft estimate (identifying details replaced with placeholders):
[PASTE DRAFT HERE]

For each checklist item, answer PRESENT, MISSING or UNCLEAR, quote the line you relied on, and list anything in the draft that reads like a promise, a contract term or a clinical claim.

A realistic reply (illustrative) looks like this: items 1, 3, 5 and 6 present; item 2 unclear because the draft says "anxiety" without a code and without saying whether a diagnosis has been determined; item 4 missing the TIN; item 7 present; item 8 present but the draft adds "by booking you agree to these terms", which reads as a contract term. All three flags are useful. The first is a judgement call for the clinician, the second is a lookup, and the third is a wording fix that would otherwise have contradicted the disclaimer.

Four mistakes the check catches, with the fix for each

The estimate is worded as an agreement

A practice adds "client agrees to pay" to the bottom because it matches the intake form. CMS's model wording says the estimate is not a contract and does not require the client to use the provider. Keep the fee agreement in your informed-consent paperwork and let the estimate stay a statement of expected charges.

The diagnosis field is filled before there is a diagnosis

The form says the diagnosis is listed "if determined". Entering a provisional code to satisfy a template can create a clinical statement the client has never discussed with you. At intake, leave it blank or tick the not-determined option and state that the evaluation will confirm whether a diagnosis applies. Your estimate should still cover the evaluation fee, because that is the service you are certain to deliver.

Quantity is a guess with no basis

"Weekly for six months" becomes 26 sessions in one practice's template and 12 in another's. Pick a number you can defend from your usual pattern, state it, and say it may vary. If you cannot defend a number, estimate the evaluation and the first block of sessions and say that an updated estimate follows. That is more honest than a large figure that looks reassuring but will not match the bill.

Add-on charges sit outside the estimate

Reports to schools, letters for an employer or a phone call between sessions get billed later with no mention in advance. If you expect to charge for them, name the rate in the notes. A bill that is $400 or more above the estimate for your practice is the trigger for a dispute under CMS's process, which the client must start within 120 days of getting the initial bill, so a surprise charge of that size is exactly what the estimate is meant to prevent.

A second illustration: a client who books couples therapy

A couple books joint sessions, and one partner is the person paying. The self-pay rule is tied to the individual, so ask who the client of record is. If both are your clients with separate records, each may need their own estimate. If the paying partner is the only client of record and the other attends as a participant, the estimate goes to the client of record. This is a billing-structure question your adviser should answer once, and your template should then reflect it. The AI check will not know which is true, but it will notice if your draft names two people on one estimate and prompt you to confirm.

A third illustration: a sliding-scale fee

A practice with a sliding scale lists a fee range in its public materials, and the estimate then states one figure per client. The estimate must reflect what you actually expect to charge that client, not the top of the range or the average. Record how the fee was set, such as a signed income band, and keep it with the estimate. If the fee is reviewed after six sessions, write that into the notes so the review is not a surprise.

The covering message that goes with the estimate

The estimate is a form; the client also needs a human sentence or two. Here is an illustrative covering email you can load into your booking software as a template. It uses placeholders and avoids anything clinical.

Subject: Your estimate of fees for therapy with [PRACTICE NAME]

Hello [first name],

Thank you for booking. Attached is a written estimate of what I expect therapy to cost, based on what we agreed when you booked. It covers an intake appointment and an expected [NUMBER] sessions.

The estimate is not a contract and you are under no obligation to see me. If anything in it looks different from what you were told, or you would like to talk it through before your first appointment, reply to this email or call [NUMBER].

Please keep this estimate. If a bill from my practice is ever $400 or more above it, you have the right to dispute that bill, and the attached document explains how.

[your name]

Two details matter. The email points to the dispute right, so the client is not hearing about it first from a stranger. And it invites questions before the first session, which is cheaper than answering them after a bill arrives. If your client list includes people who prefer a phone call, record the preference on the booking form and follow it, since the form asks for the contact preference for a reason.

A fourth illustration: a client who switches to self-pay mid-treatment

A client who started with insurance loses coverage after six sessions and carries on privately. From the day they become self-pay, the rule applies to the care that follows, so the practice issues an estimate for the remaining expected sessions rather than assuming the old fee agreement still covers things. Name the date the funding changed in your internal note, state the new per-session fee if it differs from the insured rate, and send the estimate on the self-pay timeline. A quick AI check on the placeholder version confirms nothing was dropped when you copied an older estimate across, which is how a stale practice address or an old fee ends up on a new document.

Turning the estimate into a process you can repeat

A template only helps if the estimate goes out without you remembering to send it. The steps below take about an hour to set up in most practice software or in a document merge you own.

1. Tag self-pay at booking. Add a single yes/no field to the booking form: "Will you use insurance for this care?" A "no" is your trigger, and so is a client who says they will use insurance and then withdraws.
2. Generate from a master. Keep one master estimate with your fee schedule, codes, NPI and TIN stored once. Merge client details in. Updating a fee then means editing one document.
3. Set a deadline reminder. The due date is one or three business days from booking, depending on how far ahead the session is. A reminder at the end of the same business day keeps you inside the window.
4. Run the placeholder check. Each time you change the master, run the AI checklist prompt once on the placeholder version. You are checking the template, not each client's estimate.
5. Send and keep a copy. CMS tells consumers to keep their estimate in a safe place, and you need your own copy to show what was issued and when. Store it with the client's financial record, not in the clinical note.
6. Review quarterly. Fees change, codes change and the form may be updated. A quarterly check of the CMS page and your master keeps the template current.

If the booking tools you use can send an automated message with an attachment, that handles delivery. The practice software and AI add-ons tutorial explains what your current software may already include, and AI for superbills and client invoices picks up where the estimate leaves off.

Checking the numbers before you send

An AI check of structure is not a check of arithmetic or fees, so do these by hand, which takes two minutes.

• Multiply and add. Quantity times fee for each line, then the total. In the example above, 12 sessions at $150 is $1,800, plus the $200 intake gives $2,000. A wrong total is the easiest error to make and the easiest to dispute.
• Compare with your published fee. If your website or booking page lists $150, the estimate cannot say $165 without an explanation.
• Match codes to the service. The code on the estimate should be the one you will actually bill.
• Read it as the client. Could someone with no billing knowledge say what they will pay in total and what could add to it?

Where this stops and your adviser starts

Everything here is about the practical workflow. State rules differ, professional bodies publish their own guidance, and CMS may update the form or the process. Keep a short list of questions for a compliance adviser or your professional association: same-day bookings, couples and family sessions, group practices, updates to a plan of care, and how long to retain estimates. Once you have the answers, write them into the master template and the booking script, and the AI check becomes a routine rather than a rescue. For the wider picture of keeping client data out of the wrong tools, the tutorial on vendors that sign a BAA shows who to ask and what to look for.

Questions therapists ask about estimates

Does a client with insurance who pays out of pocket get an estimate?

Yes, in most cases. The CMS form is for people who are uninsured and for people who have insurance but choose not to use it for the care. If a client says at booking that they will pay privately, treat them as self-pay and issue the estimate on the same timeline as any other self-pay client.

Is the estimate a contract the client must accept?

No. The CMS model wording says the estimate is not a contract and does not oblige the client to use you. Keep your fee policy and consent paperwork as separate documents, and do not word the estimate as an agreement to pay.

What if the client attends more sessions than I estimated?

The estimate covers what you reasonably expected at the time. If the plan changes in a material way, such as moving from weekly to twice weekly, issue an updated estimate rather than letting the bill drift. Ask your compliance adviser how your state treats updates.

Can I paste the client's name and details into ChatGPT to check it?

Do not. Check the structure with placeholders such as [CLIENT] and [DATE OF BIRTH], then add the real details in your practice system. Names, dates of birth and diagnoses count as protected health information, and a standard ChatGPT Business plan does not come with a business associate agreement.

Who is the convening provider for a group practice?

CMS's consumer guidance says estimates currently list charges for a single provider or facility, even when several are involved. For a group practice, ask your billing adviser whether the practice or the individual clinician issues the estimate, and keep that choice consistent.

Further reads

• AI Tools for Psychotherapists: Diary, Invoices and Referral Replies — Invoices and referral replies once estimates are done.
• Can Therapists Use ChatGPT for Session Notes? — The privacy line between admin help and clinical notes.
• AI Note-Taking Tools for Therapists: A Confidentiality Checklist — A confidentiality checklist for AI note tools.
• Automated Booking Systems for Therapists: Which Ones Automate What? — Booking tools that can send the estimate at scheduling.
• AI Usage Policy for a Medical Practice: Template and HIPAA Rules — Write down which AI uses your staff may make.
• AI Marketing for Therapists: What to Say and What to Leave Out — Testimonial and outcome-claim rules as the spine: before-and-after examples for a directory profile, website copy and a newsletter drafted with AI.
• AI Tools and AI Development: The Complete 2026 Guide — the AI hub, including every tutorial in the AI-for-business series.

Sources: CMS Medical bill rights pages on good faith estimates for people without insurance (checked 4 November 2026); the CMS standard form 'Good Faith Estimate for Health Care Items and Services' and its instructions; OpenAI help articles on business associate agreements and on ChatGPT for Clinicians (checked 4 November 2026); CPT time ranges for psychotherapy codes from a published hospital compliance guide.