GOOD FAITH ESTIMATE (NO SURPRISES ACT NOTICE)

Required for all self-pay providers

Petti Pathways Counseling PLLC

You have the right to receive a Good Faith Estimate explaining how much your medical and mental health care services may cost.

What Is a Good Faith Estimate?

A Good Faith Estimate is a written explanation of:

• Expected charges for scheduled services

• Based on the information known at the time

• Applies to clients who are:

  • Uninsured

  • Self-pay

  • Not using insurance benefits

Your Rights Under the No Surprises Act

If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to:

• Dispute the bill through the federal patient-provider dispute resolution process

You will receive a Good Faith Estimate:

• At least 1 business day before a scheduled service

• Or within 3 business days of booking an appointment

What This Notice Means

• Costs may vary based on treatment length, clinical need, or additional services

• Emergency or extended services may change original estimates

• This notice does not replace your signed financial or consent forms

Questions About Your Estimate?

Please contact:
Petti Pathways Counseling PLLC
Email: info@pettipathways.com
Clinical Director: Seqouia Pettigrew

For more information about your rights:
www.cms.gov/nosurprises