• The patient’s name and date of birth;
  • A description of the primary item or service being furnished to the patient (and if applicable, the date the primary item or service is scheduled);
  • An itemized list of items or services that are “reasonably expected” to be furnished;
  • Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;
  • The name, National Provider Identifier, and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished. (APA recommends using a business TIN rather than your SSN);
  • A list of items or services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service; 1
  • A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
  • A disclaimer that the information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate; and
  • A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. This should include instructions for where the patient can find information about how to initiate the dispute resolution process, as well as a statement that the initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient; and
  • A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

The required disclaimers are included in the CMS template cited above.

1 If there are such separately scheduled services, the estimate should also include a disclaimer that (a) separate good faith estimates will be issued upon scheduling or upon request of the listed items or services, (b) for items or services included in this list, information such as diagnosis codes, service codes, expected charges and provider or facility identifiers do not need to be included, as that information will be provided in separate good faith estimates upon scheduling or upon request; and (c) instructions for how an uninsured (or self-pay) individual can obtain good faith estimates for such items or services.

Do these requirements apply to existing/ongoing patients?
The rule makes no distinction between current and future patients. These new disclosure requirements would presumably apply to continued services furnished to existing patients as well as to new patients.