Risk Adjustment Audit Opt-Out Form

Risk Adjustment Audit Opt-Out Form
Associates In Psychotherapy
Deerfield • Evanston • Chicago • Barrington
(866) 220-8371
Client Information
Name

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Address

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Purpose of this form
As part of our commitment to maintaining transparency and protecting your privacy, we periodically participate in risk adjustment audits. These audits are conducted by insurance companies or their agents to ensure accurate documentation and billing practices. During this process, some of your health information may be reviewed.

You have the right to opt out of these audits if you do not wish your information to be included. This form allows you to indicate your decision.
Acknowledgement
By signing this form, I acknowledge the following:

1. I understand the purpose of risk adjustment audits and their role in ensuring accurate documentation and billing practices.
2. I have been informed of my right to opt out and the implications of my decision.
3. I understand that opting out will not affect my care or treatment in any way.
Opt-Out Selection

I DO NOT authorize the release of my health information for risk adjustment audits.
Client Signature

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Client Information