A sample patient consent form for APCM services

The Centers for Medicare & Medicaid Services (CMS) introduced new codes this year for advanced primary care management (APCM) for patients with chronic conditions. APCM services are subject to cost-sharing, with some exceptions for “qualified Medicare beneficiaries,” and they require patient consent. Consent may be written or verbal, but it must be documented in the patient’s medical record.

According to CMS guidance, patients can only give consent after being informed of the following:

• Only one clinician can furnish and be paid for the patient’s APCM services during a calendar month,
• The patient has the right to stop APCM services at any time,
• The patient may incur out-of-pocket costs for APCM services.

Practices providing APCM services can either incorporate the required language into their general consent form (see an example) or create a dedicated consent form for APCM services. For the latter, this APCM patient consent template can be downloaded for use in practice; it was adapted with permission from Harder Family Practice in Augusta, Kan.

Posted on March 18, 2025 by FPM Editors.