This is our Good Faith Estimate as part of the No Surprises Act.  We are sharing a customizable word document with you.

With this product you will receive: 

  1.  The GOOD FAITH FORM we use 
  2. The Office Posting we use 
  3. A word document explaining what you need.

Codes for both psychotherapy and Nutrition Therapy Services as well as common diagnosis we use.

A statement on why we defer diagnosis

A statement on frequency of treatment/sessions

This is divided into sections in accordance with the NSA/GFE part two (private practice providers).

*Note that all providers must give the GFE by Jan 1 2022 if you have patients that do not use insurance, are cash pay, or do not have insurance.  You can customize this form for your use.

The statement on the product image is what we use on our website.

All customizable for your practice


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  • Very helpful!

    My head was spinning trying to figure out what this new law meant for me as a private practice dietitian, but this outlines everything you need to know about complying. You will have to go through and replace the practice name and information with your own, but it is very simple to do since the documents are editable. Be sure to read through thoroughly and customize for your practice!

    • Thank you! Very glad it is helpful. Yes, great tips to read through. I have used templates before and made this mistake. The find and replace is a great way to double check. I appreciate your time to review!

  • Essential!

    An essential resource for Dietitians trying to navigate this new requirement! Many thanks!

  • So helpful!

    Outlines everything you need to be compliant with the new law. The forms are very easy to customize. Thank you for sharing!

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