Patient Safety Organization Forms

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Patient Safety Organization Forms

NOTE: The Department of Health and Human Services (HHS) issued the Patient Safety Rule (PDF file, 450 KB; PDF Help) to implement the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), which authorizes the creation of Patient Safety Organizations (PSOs). The Patient Safety Rule became effective on January 19, 2009.

The Agency for Healthcare Research and Quality (AHRQ) administers the PSO provisions of the Patient Safety Act. AHRQ has prepared a form that an organization must use to certify that it meets the requirements to become listed as a PSO and two forms that a listed PSO must use when certifying compliance with other statutory requirements that are incorporated in the Patient Safety Rule. AHRQ has also prepared a form that a PSO seeking continued listing by the Secretary of Health and Human Services must submit before its period of listing expires (i.e., 3 years from its effective date and time of initial listing). Please note that submitting the PDF version of these forms, either via e-mail or as hard copy, is preferred by AHRQ. For questions about the PSO listing process and form submission, please contact the PSO Office.

PSO Certification for Initial Listing (PDF File, 129 KB; PDF Help)

PSO Two Bona Fide Contracts Requirement (PDF File, 100 KB; PDF Help)

PSO Disclosure Statement (PDF File, 119 KB; PDF Help)

PSO Certification for Continued Listing (PDF File, 40 KB; PDF Help)