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Disclosure Statement Form

NOTICE:  PSO online form submission is not currently available.  For all PSOs or prospective PSOs that want to submit a listing form at this time, please click on the PDF download icon [ ] below, complete the form and send the form to Thank you for your patience as we update the online submission tool.

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), and its implementing regulation, authorize the creation of Patient Safety Organizations (PSOs). The Agency for Healthcare Research and Quality (AHRQ), of the Department of Health and Human Services (HHS), administers the provisions of the Patient Safety Act and Patient Safety Rule dealing with PSO operations. Information related to PSOs is available on AHRQ's PSO website at

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