No Surprises Act and Good Faith Estimate

The No Surprises Act is a federal law which provides you with the right to a good faith estimate

of the cost of services at this practice. This is for clients who are not using insurance or are self-

pay. However, Ohio licensing board rules require clinicians to provide you with the actual cost of

charges in a written informed consent form to which you must agree prior to receiving services.

That will be available to you prior to you being seen for services and prior to any billing. If you

receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute that bill.

Make sure to save a copy or picture of your Good Faith Estimate. You will be notified in

advance of any changes to Calm Waters fees, and you will sign a new informed consent form

with the updated fees. For questions or more information about your right to a Good Faith

Estimate, or how to dispute a bill, visit www.cms.gov/nosurprises.