Bill exceeds your Good Faith Estimate

If you were uninsured or self-pay, received a Good Faith Estimate, and the bill came in at least $400 above it, you can start the federal patient-provider dispute resolution process. The window is 120 calendar days from the date of the first bill, and the fee is $25.

The lever: A Good Faith Estimate is a federal promise with a federal remedy attached: $400 over and you can bring in an independent reviewer.

Fill this letter in →All seven letters

⏳ Good Faith Estimate dispute window: 120 days

You can start the federal patient-provider dispute process when a provider bills at least $400 over their Good Faith Estimate. There is a $25 administrative fee, refunded against what you owe if the reviewer agrees with you.

Date of your first bill

example — counting from today

120 days left — this window closes on November 29, 2026. Send by certified mail with return receipt so you can prove the date it arrived.

The letter

Bracketed placeholders are the fields you fill in. The generator does the filling and keeps your draft in your browser.

[YOUR FULL NAME]
[YOUR ADDRESS]

[TODAY'S DATE]

[WHO YOU ARE WRITING TO]
[THEIR ADDRESS]

Re: Account [ACCOUNT OR BILL NUMBER] — bill exceeds Good Faith Estimate
Date of service: [DATE OF SERVICE]

To whom it may concern,

I am an uninsured/self-pay patient. Before receiving care on [DATE OF SERVICE], I was given a Good Faith Estimate of [AMOUNT ON YOUR GOOD FAITH ESTIMATE]. The bill I received, dated [DATE OF THE FIRST BILL], is [AMOUNT ACTUALLY BILLED] — substantially more than the estimate.

Under the federal No Surprises Act, an uninsured or self-pay patient billed at least $400 more than their Good Faith Estimate may initiate the patient-provider dispute resolution process, which places the bill before an independent third-party reviewer. That process must be started within 120 calendar days of the date of the initial bill.

Before initiating that process, I am asking you to review this account and either adjust the charges to the estimated amount or explain in writing, item by item, what changed between the estimate and the bill.

Please confirm receipt of this letter and treat the account as under review. I am tracking the 120-day window from [DATE OF THE FIRST BILL].

Sincerely,

[YOUR FULL NAME]

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This is a template, not legal advice.

What this letter rests on

After you send it

Day 14Call to confirm the review is logged. Ask for the itemized comparison between the estimate and the final bill in writing.
Day 30No adjustment or explanation? Prepare the federal dispute — the CMS initiation form and the $25 fee are the next step, well inside the 120-day window.
Day 90Do not let the window lapse. If the provider has not resolved this, file the dispute with CMS now rather than waiting for a reply that may not come.

The case tracker turns this schedule into dated reminders for one specific bill, stored in your browser.

Frequently asked questions

Who gets a Good Faith Estimate?

Uninsured and self-pay patients who schedule care, or who ask for an estimate. It must list the expected charges for the scheduled item or service. If you are insured and using your benefits, this dispute route is not yours — the surprise-billing letter is more likely the right one.

What exactly is the $400 threshold?

The dispute process is available when a provider or facility bills you at least $400 more than that provider's Good Faith Estimate for the same care. It is per provider, not per total bill, so an itemized estimate and an itemized bill are what you compare.

How long do I have, and what does it cost?

You must initiate the dispute within 120 calendar days of the date on the initial bill, and there is a $25 administrative fee. If the reviewer decides in your favor, that fee comes off the amount you owe. The deadline calculator on this page counts the days from your bill date so the window does not quietly close.

Should I send this letter before filing the federal dispute?

Many bills get corrected at this stage without a formal process, and it costs a stamp. But do not let the letter consume your window: the follow-up schedule here deliberately pushes you to file by day 90 if nothing has moved, leaving a month of margin.

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Other situations

Request an itemized bill Dispute a billing error Billed above the cash price

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