Forms

Patient Safety Organizations (PSOs) may complete and submit forms online. Forms can also be downloaded for completion and emailed or mailed. The AHRQ PSO Program will acknowledge receipt of forms submitted by PSOs within two business days. For questions about form submission, please contact the AHRQ PSO Program.

Certification for Initial Listing Form

AHRQ has prepared a PSO Certification for Initial Listing Form for any entity that wants to become a listed PSO. Prior to completing and submitting this form, AHRQ encourages entities to contact the PSO Program. Applications can be submitted at any time.

Two Bona Fide Contracts Form

To remain listed, each PSO is required to have two bona fide contracts with different health care providers for the purpose of receiving and reviewing patient safety work product during each successive 24-month period beginning with the date of initial listing. This form must be submitted no later than 45 calendar days prior to the last day of each pertinent 24-month assessment period.

The PSO's listing on the AHRQ PSO website will show certain important facts:

  • A PSO's initial date of listing
  • The period during which the next two bona fide contracts requirement must be met
  • PSOs are encouraged to refer to the following sections of the Patient Safety Rule for more information on the Bona Fide Contracts Requirement:

Disclosure Statement Form

Every time a PSO enters a Patient Safety Act contract, the PSO will need to determine whether it has other relationships with the same provider that require it to submit a Disclosure Statement Form. AHRQ recommends contacting the PSO Program to determine whether this form is necessary.

PSOs are encouraged to refer to the following sections of the Patient Safety Rule for more information on the Disclosure Statement Requirement:

  • Section 3.102(d)(2)
  • Section 3.104(c)

Continued Listing Form

A listing with AHRQ automatically expires after 3 years if it is not renewed. PSOs must submit the Certification for Continued Listing Form no later than 75 days before the expiration of the 3-year period. Before submitting the form, AHRQ will contact the PSO to schedule at least two calls to review the PSO's progress in meeting those requirements. These discussions will begin approximately 6 months before the listing expires.

See Section 3.102(b)(1)(ii) of the Patient Safety Rule for more information.

PSO Change of Listing Information Form

As required by section 3.102(a)(1)(vi) of the Patient Safety Rule, a PSO must promptly notify the Secretary during its period of listing if it can no longer comply with any of its attestations and the applicable requirements or if there have been any changes in the accuracy of the information submitted for listing. A PSO must notify AHRQ of all such changes, whether major or minor (examples include, but are not limited to, acquisition of the PSO or its parent organization by a health insurance issuer; change or addition of a parent organization; change in address, phone number or other contact information; new PSO Point of Contact or Authorized Official). This is an administrative form which is used by a PSO to notify AHRQ of such changes.

PSO Profile

The PSO Profile gathers information on the types of healthcare providers and settings that PSOs are working with to conduct patient safety activities in order to improve patient safety. For example, data reflecting the 2016 reporting period (i.e., the 2016 calendar year) should be submitted no later than February 28, 2016. PSOs should update their PSO Profile online by February 28th of each year. The information should be entered electronically at the PSO Privacy Protection Center website. Please contact support@psoppc.org for further information.

PSO Voluntary Relinquishment Form

Section 3.108(c) of the Patient Safety Rule addresses voluntary relinquishment of listing. A PSO will be considered to have voluntarily relinquished its status as a Federally-listed PSO if the Secretary accepts notification from a PSO that it wishes to voluntarily relinquish its listing. This PSO Voluntary Relinquishment Form is used by a PSO to provide the attestations required to initiate the voluntary relinquishment process.

Patient Safety Confidentiality Complaint Form

The Department of Health and Human Services' Office for Civil Rights (OCR) is responsible for the implementation and enforcement of the confidentiality provisions of the Patient Safety Act and Patient Safety Rule. Confidentiality provisions permit patient safety work product (PSWP) to be disclosed only in accordance with specific disclosure permissions (see section 3.206 of the Patient Safety Rule). A complaint can be filed against a person or organization that impermissibly disclosed PSWP using the Patient Safety Confidentiality Complaint Form. OCR provides information on how to file a Patient Safety Confidentiality Complaint.