Use the Good Faith Estimate template

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Level: beginner

Objective: 

We’ll explain how to use the Good Faith Estimate (GFE) template that will support your compliance with the No Surprises Act. This template is different from our other form templates in that you, the customer, will fill it out instead of your client.

How to access the GFE template:

1. Open up the form builder in webmail

Click on the Form Builder button at the top right of your webmail window. 


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2. Select Create form

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How to choose the GFE template:

The templates are divided into two categories: General and Healthcare. 

3. Scroll down the Healthcare category until you find the Good Faith Estimate template

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4. Click Preview or use

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5. To add the template to your collection of forms, click Use this template

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Please note that this will count against your plan’s number of allotted forms.

How to edit the template:

This template must be edited to include your information. 

6. Click on the button at the top of the template that says Edit business information

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This will open up a window that will allow you to edit the information of your Facility or provider.

You can also click anywhere over the business information section to open the window.

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7. Click the Services tab to allow you to edit the information about your services

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Make your changes to Facility or provider and Services so they accurately reflect your practice. 

8. Click Apply

Note: You can also edit the disclaimer at the bottom of the form. However, the disclaimer used in this template is modeled on the Centers for Medicare & Medicaid Services (CMS) disclaimer and fulfills the requirements of the No Surprises Act. 

9. Publish your edited form by clicking on Publish in the top left of the form builder 

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You must fill out all of your business information before publishing. The Publish button will be highlighted in blue when your information is complete.

How to use the form:

10. Click on Use form at the top of the form

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The Use form button opens the form up in a webpage. 

Tip: Bookmark this page so you can quickly access the template when you need to fill it out for a new client.

11. Fill out the form with your client’s information 

Note that you must include your client’s email address. When you click Submit, a copy of the completed form will be sent to that email address.

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12. Fill in the information about your services and the total expected charges

13. Click Submit at the bottom of the form

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Your client now has your Good Faith Estimate, and you have an online record that you sent it to them.

Next Steps:

For information about the No Surprises Act and why you might need to send a Good Faith Estimate to your clients, read our blog post No Surprises Act Summary: What your small healthcare practice must do.

Resources: 

Getting started  
Building a basic web form
Use conditional visibility in your web form