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Good Faith Estimate Template

Blank template for individual private practice clinicians billing self-pay or uninsured patients, based on recommendations from The Trust and the OMB template.

Although I have tried to provide a quality resource, Jon Reeves, PhD PLLC does not imply, and makes no gaurantee, that this form satisfies the requirements of the No Surprises Act. If you need any form provided here to satisfy legal requirements, consult a lawyer.

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