The following handouts are provided to all clients of Alexandria Community Services Board behavioral health programs at intake and are reviewed annually.

• Confidentiality and Your Health Record | English  | Amharic | Spanish
• Service Handbook | English | Amharic | Spanish
• Clients Rights and Responsibilities | English | Amharic | Spanish

Disclosure of Rights and Requirements for the No Surprises Act

A new Federal law. “The No Surprises Act”, requires that health care providers give written cost estimates for services. The written estimate is referred to as a “Good Faith Estimate”. The law is intended to protect people from surprise medical bills. This is called No Surprise Billing.

• If you schedule an appointment or service at least three business days in advance, you must receive a Good Faith Estimate, at least one business day after scheduling the appointment.

• If you scheduled an appointment or service at least 10 business days in advance, you must receive a Good Faith Estimate within three business days after scheduling. (Emergency services is not required to give estimates prior to service.)

The notice can be provided to you via email or standard mail. If you have an insurance that Alexandria Services Board (ACSB) participates in, your insurance will be billed, and if the service is covered by your insurance, you will not be required to pay any additional amounts outside of Copay, Deductible and Co-insurance.

The estimates that you receive are based on the full cost of the service which is the maximum you would owe for the service. Your actual cost may be lower than this amount based on your income and family household size. The amount you will have to pay is based on a sliding scale and is called the monthly liability. (See attachments: liability fee scale and fees for services.)

At intake and annually your liability will be determined. At intake, services will be recommended to you in addition to discussing “Freedom of Choice”. This means that your provider will explain the recommended services and alternatives, both within and outside of ACSB. Throughout your treatment episode with ACSB you may receive one or more services simultaneously or you may move from one service to another. Each time new services are recommended and accepted by you, you will be given a cost estimate and a choice of alternative services.

Payment disputes between uninsured (or self-pay) consumers and providers

After you get the care, if you’re billed an amount that’s more than $400 over the estimate you received, you can use a new patient-provider dispute resolution process to determine a payment amount. This process uses a third-party arbitrator to review your good faith estimate, final bill, and information submitted by your provider or facility.

You can use this dispute process if you meet these 5 conditions: You’re uninsured or self-pay (meaning you have insurance but don’t plan to have your health insurance pay for the care)

• You got medical items or services on or after January 1, 2022
• You have a good faith estimate from your provider or the facility who provided your care
• You got a bill within the last 120 calendar days
• The difference between the good faith estimate and your bill is at least $400

Attached is the full disclosure related to No Surprise Billing and a link to the Center for Medicaid Services. If you have further questions, please contact our reimbursement department between the hours of 8am to 4pm at 703.747.3444.

See the Alexandria CSB Ability to Pay Scale and the Fee for Services Scale .

All clients of Alexandria Community Services Board (CSB) programs have the right to file a complaint about a program and to seek a satisfactory resolution. Please see the department policy for details. The following actions will be taken when a client has a complaint or is not in agreement with a program decision.

1.  Clients may express complaints in a variety of manners: gestures to indicate displeasure if they are unable to verbally communicate, verbally, in writing or by completing the dispute resolution form available in all lobbies and public areas of the CSB including in the Residential Program group homes.  

2.  The complaint can be made to any member of the CSB staff. In all cases the client and/or their designee will be offered the contact information for CSB human rights advocate.  

3.  The client will receive a response within 24 business hours of submitting the complaint. The individual making the complaint can have a family member, friend, or anyone of their choosing present during the resolution process and/or make a complaint on their behalf. If the client has an authorized representative (AR) or guardian, the staff person will inform and involve that individual in the resolution of the complaint. The client is encouraged to discuss their concerns and work with staff to attempt to resolve the problem as quickly as possible. Staff will institute a resolution within ten business days. The complaint and resolution will be documented in writing and provided to the client.  

4.  If after the program supervisor’s attempt to resolve the complaint, the client, guardian or AR is not satisfied with the resolution, the client will be informed of the appeal process and given the Center Director’s contact information and asked to appeal to the Center Director. The Center Director or their designee will investigate further and provide a written response to the client within five business days.  

5.  If the client is still not satisfied with the resolution, they have five working days to file a complaint with the CSB Executive Director. The Executive Director or their designee will investigate further if appropriate and provide a written response to the client within five business days.  

6.  If the client is still not satisfied with the resolution, they have five working days to file a complaint with the Department of Community and Human Services Department Director. The Department Director or their designee will investigate further if appropriate and provide a written response to the complainant within five business days. The decision of the Department Director is final.

These forms, available in four languages, are for general authorization to use and exchange information.  Also available are forms specific to the release of information from the Alexandria Sexual Assault Center and Domestic Violence Program.