RESEARCH PARTICIPATION INTEREST FORM

Thank you for your interest in the Payer Payment Impact Study.

The Payer Payment Impact Study is a multi-phase research initiative examining payer reimbursement experiences and their relationship to the financial stability of outpatient behavioral health organizations, workforce capacity, healthcare delivery, patient access, and continuity of care.

This Participation Interest Form is the first step for individuals and organizations that would like to be considered for participation in the study.

PURPOSE OF THIS FORM

The purpose of this form is to help the research team identify individuals and organizations interested in participating in the Payer Payment Impact Study and determine which phase or type of participation may be appropriate.

The form collects preliminary information about you, your professional role, your organization, geographic location, and your interest in participating.

This is not the research survey. You will not be asked through this form to provide detailed claims information, financial records, patient information, payer documentation, or other study data.

IMPORTANT INFORMATION REGARDING STUDY PARTICIPATION

Phase 1 and Phase 2 of the Payer Payment Impact Study will use a controlled state-based data collection approach.

Phase 1 pilot data collection is currently limited to behavioral health practices located in the following jurisdictions:

Massachusetts • Georgia • North Carolina • Washington, DC • Virginia • Maryland

If your practice or organization is not located in one of the current Phase 1 jurisdictions, we still encourage you to complete this Participation Interest Form. Your information will allow the research team to identify individuals and organizations interested in participating as the study expands.

Participants located outside the Phase 1 research jurisdictions may be contacted when Phase 2 or Phase 3 recruitment and interviews become available for their state or region.

Submitting this form also does not enroll you in the study and does not constitute informed consent to participate in research.

To receive future participation opportunities, please consent to joining the Payer Payment Impact Study research email list when completing this form.

Your contact information will be used specifically for communications related to the Payer Payment Impact Study, including:

Upcoming research recruitment and enrollment opportunities
Phase 2 and Phase 3 participation announcements
Study interview opportunities
Important participant information and research-related updates

You will not be added to JLW Medical Management Consulting's general marketing email list through this research consent.

Please note: Completing this form does not guarantee selection for the study and does not constitute formal enrollment or informed consent to participate in research. If your state and participant category become eligible for an upcoming research phase, the research team will contact you with additional information regarding eligibility, participation requirements, informed consent, and next steps.

We encourage interested behavioral health organizations and professionals from all U.S. states and Washington, DC to submit an interest form, even if their location is not currently included in Phase 1.

First name

Last name

Practice Name

Position

Professional Email

I agree to receive email communications related to the Payer Payment Impact Study, including study updates, recruitment opportunities, interview invitations, and information regarding future phases of the research.

Phone

Practice Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Check the box if your practice is not located in a current Phase 1 study state, but you are interested in a future phase.

Has your organization or professional work involved issues related to denied, delayed, or underpaid payer reimbursement?

YES

Approximately how many clinicians are affiliated with your organization?

Organization Type

If you selected “Other,” please specify the type of outpatient behavioral health organization you operate or represent.

How are you interested in participating in the Payer Payment Impact Study?

By submitting this form, I understand that I am expressing interest in learning more about the Payer Payment Impact Study. Submission of this form does not enroll me in the research study or constitute research participation. If I am eligible for an upcoming phase of the study, the research team may contact me with additional information regarding participation requirements, informed consent, and next steps.