# Prepare a Good Faith Estimate for a self-pay patient

Builds a No Surprises Act Good Faith Estimate for uninsured or self-pay patients with required elements, timing, and a plain-language cover note.

- Topic: Finance & Accounting
- Framework: Few-Shot
- Level: Advanced
- Tags: Finance, Analyze, Fill-in Template
- Source: https://www.thinkwithprompt.com/prompts/prepare-a-good-faith-estimate-for-a-self-pay-patient

## Prompt

```text
Help me prepare a Good Faith Estimate (GFE) for an uninsured or self-pay patient.

**Scheduled or requested service:** [e.g. "knee MRI", "outpatient procedure", "course of 12 therapy sessions"]
**Scheduling date and service date:** [DATES - or "patient requested an estimate, not yet scheduled"]
**Expected items and services with codes:** [CPT/HCPCS, quantity, our self-pay price for each]
**Co-providers or co-facilities involved:** [e.g. anesthesia, outside lab, pathology - and whether we have their estimates]
**Diagnosis codes, if known:** [ICD-10 or "not yet"]
**Our self-pay discount or financial assistance policy:** [SUMMARY]

Do this:
1. Confirm timing rules: when the GFE must be delivered based on how far ahead the service is scheduled, or after a patient request. Mark exact deadlines as [CONFIRM CURRENT RULE].
2. Build the GFE with the commonly required elements: patient details, description and date of service, itemized list with codes and expected charges, provider and facility names, NPIs and tax IDs, co-provider estimates, a list of items that need separate scheduling, the disclaimer that this is an estimate, and the patient dispute rights notice if actual charges exceed the estimate by $400 or more.
3. Flag any item likely to vary and how to state a reasonable range.
4. Write a short, plain-language cover note for the patient explaining what the estimate covers, what it does not, and who to call with questions.
5. List what we must keep on file and for how long.

Use only the prices I provide; mark anything missing as [ADD PRICE]. This is general information on federal requirements; state rules may add more. Verify with our compliance lead or healthcare counsel.
```

## What to fill in

- DATES - or "patient requested an estimate, not yet scheduled"
- CPT/HCPCS, quantity, our self-pay price for each
- ICD-10 or "not yet"
- SUMMARY
- CONFIRM CURRENT RULE
- ADD PRICE

Free to copy and use. From ThinkWithPrompt (https://www.thinkwithprompt.com/), a library of 2,663 curated AI prompts.