CMS-10479 Informed Consent to Participate in Research for Benefici

Informed Consent to Participate in Research for Beneficiaries and Caregivers
Title of Research: Evaluation of the Multi-payer Advanced Primary Care Practice (MAPCP)
Demonstration
You are being asked to be in a research study. This form explains what the study is about and what
it asks you to do.
The Evaluation of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration is a
research study. The study is paid for by the U.S. Centers for Medicare and Medicaid Services
(CMS). It is led by RTI International, the Urban Institute, and The Henne Group. The study will
help learn how well advanced primary care practice works when it has support from Medicare,
Medicaid, and private health plans.
If you agree to be in this research study, you will be asked to join a small group discussion, called a
focus group. The focus group will take about two hours. The focus group will ask questions about
your primary care doctor’s office and your experience with services you receive there. If you are a
caregiver, you will be asked about services provided to the person whom you care for and their
experiences.
We believe there are minimal risks from being in this focus group. We will make every effort to
protect your confidentiality, but this cannot be guaranteed. Your name will not appear in any reports
that are written about the focus group. Being in this study will have no direct benefit for you. Your
health care will not change one way or the other. You will receive a $50 gift card for your time.
The Institutional Review Board (IRB) at RTI International has approved this research plan. Your
decision to be in this focus group is up to you. You can refuse to answer any question. You can
leave the focus group at any time.
If you have any questions about this study, please call Nancy McCall, the RTI Project Director, at
202-728-1968. If you have questions about your personal rights in this study, please call RTI’s
Office of Research Protection at 1-866-214-2043 (a toll-free number).
By signing below, you are saying that you have read this form, have gotten answers to your
questions, and have freely decided to be in this research study.
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Signature of Participant
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Printed Name of Participant

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Signature of Person Obtaining Consent
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Printed Name of Person Obtaining Consent