Good Faith Estimate (GFE) Generator
Build, print, and archive CMS-compliant Good Faith Estimates under 45 CFR § 149.610 for uninsured and self-pay patients with full statutory dispute rights.
Configure Good Faith Estimate (GFE)
Itemized Expected Services & Co-Provider Charges
GOOD FAITH ESTIMATE
For Healthcare Items & Services — Established under 45 CFR § 149.610
Aethera Medical Practice Network
Billing NPI: 1942857193
Direct Contact: (555) 234-5678
Date Generated: September 8, 2026
Diagnostic Colonoscopy with biopsy of polyps
| Service Role | CPT / HCPCS | Description of Items & Services | Service Provider / Facility | Expected Charge |
|---|---|---|---|---|
| Primary Procedure | 45380 | Colonoscopy, flexible, with biopsy, single or multiple | Primary Gastroenterologist | $650 |
| Facility Fee | 0490 | Ambulatory Surgical Center (ASC) facility fee | Metropolitan Endoscopy Pavilion | $1,100 |
| Anesthesia | 00812 | Anesthesia for lower intestinal endoscopic procedures | Associated Anesthesia Care LLC | $480 |
| Pathology / Lab | 88305 | Surgical pathology, gross and microscopic examination | Apex Reference Pathology Labs | $220 |
| Total Estimated Out-of-Pocket / Self-Pay Cost: | $2,450 | |||
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
Your Right to Dispute: If you are billed for $400 or more than this Good Faith Estimate from any single provider, you have the right to dispute the bill through the federal Patient-Provider Dispute Resolution (PPDR) process.
You must start the dispute process within 120 calendar days of the date on the original bill. There is a small administrative fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity agrees with you, you will only have to pay the amount on this Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.
Authorized Provider / Clinic Billing Officer Signature
Patient / Responsible Party Acknowledgment Signature
Automate No Surprises Act & Front-End Billing for Your Practice
Aethera provides integrated front-end eligibility verification, automated Good Faith Estimates, and transparent self-pay workflows that eliminate patient billing complaints and maintain 100% federal audit compliance.
No Surprises Act Compliance & Good Faith Estimate FAQ
Who is required to receive a Good Faith Estimate?
Under federal law (45 CFR § 149.610), all healthcare providers and facilities must provide a Good Faith Estimate of expected charges to individuals who are uninsured or self-pay (not intending to submit a claim to their insurance) upon scheduling or upon request.
What are the mandatory statutory delivery deadlines?
If scheduled at least 3 business days in advance, the GFE must be furnished within 1 business day. If scheduled at least 10 business days in advance, the GFE must be furnished within 3 business days of scheduling.
What is the $400 Patient-Provider Dispute threshold?
If the final billed charges exceed the total Good Faith Estimate by $400 or more for any single provider or facility, the patient has the statutory right to initiate the federal PPDR dispute process within 120 calendar days of the bill date.
How does Aethera automate front-end compliance?
Aethera integrates 270/271 real-time eligibility checking directly into the intake queue, instantly flagging self-pay, out-of-network, or high-deductible status, and auto-generating compliant GFE documentation before appointments are confirmed.