Forms

Patient Safety Organizations (PSOs) are encouraged to complete and submit forms online. Online submissions are acknowledged automatically. Forms can also be downloaded for completion and emailed or mailed. 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. AHRQ provides technical assistance at no cost to PSOs and entities seeking to become an AHRQ-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 healthcare 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.

Disclosure Statement Form

Every time a PSO enters a Patient Safety Act contract, and throughout the duration of the contract, the PSO will need to determine whether it has other relationships with the contracted providers 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 PSO listing with AHRQ automatically expires after 3 years if it is not renewed. In order for the PSO to be considered for an additional 3-year period, 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 offer a technical assistance call to review any questions the PSO may have about the listing requirements 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 form may be used by PSOs to notify AHRQ of such changes.

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.

Other Forms

PSO Profile

The PSO Profile gathers general information about the PSO and the types of healthcare providers and settings it serves. The PSO Profile is voluntary; if a PSO elects to submit the Profile, the information should be entered electronically at the PSO Privacy Protection Center website. Please contact support@psoppc.org for further information.

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.