CONCEPT #32 OF 100 · Medical, Dental & Clinical Practices · LAYOUT: split_settlement
No Surprises Act Good Faith Estimate (GFE) for Uninsured / Self-Pay Patients
Standard / Reference: Public Health Service Act § 2799B-6 · 45 C.F.R. § 149.610 ($400 PPDR Threshold Notice)
Why professionals use this template: Federal compliance requirement under 45 C.F.R. § 149.610 for all healthcare providers seeing self-pay/uninsured patients, including the mandatory $400 dispute-resolution notice.
144-DPI VECTOR PREVIEW · PAGE 1 OF 1
ACROFORM READY
Included Financial Metrics & Line-Item Schedule
Target Roles: Outpatient Surgery Centers, Behavioral Health Providers, Specialists & Imaging Clinics · Search Keywords: no surprises act good faith estimate template pdf 45 cfr 149.610, self pay patient good faith estimate form, 400 dollar patient provider dispute resolution notice, uninsured medical cost estimate
TOTAL GOOD FAITH ESTIMATE
$1,485.00
PPDR DISPUTE THRESHOLD
+$400.00 OVER ESTIMATE
ESTIMATE DELIVERY WINDOW
Within 1 Business Day
VALIDITY PERIOD
12 Months From Issue
| CODE | DESCRIPTION & TECHNICAL SPECIFICATION | BASIS / QTY | AMOUNT / DELTA |
|---|---|---|---|
| CPT-73721 | MRI Lower Extremity Joint (Right Knee) Without Contrast — 3.0 Tesla High-Field Scanner | Technical Component | $690.00 |
| CPT-73721-26 | Board-Certified Musculoskeletal Radiologist Diagnostic Interpretation & Written Report | Professional Fee | $245.00 |
| CPT-20611 | Ultrasound-Guided Major Joint Aspiration / Visco-Supplementation Injection (Right Knee) | Procedure + Guidance | $365.00 |
| HCPCS-J7325 | Hyaluronan Derivative Intra-Articular Injectable Supply (Single-Dose Prefilled Syringe) | Medication Supply | $185.00 |
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