Form #4 Form #4 Two-Contract Requirement Form

Form Approved


OMB No. 0935-XXXX


Exp. Date XX/XX/20XX

ATTESTATION REGARDING THE TWO BONA FIDE CONTRACTS REQUIREMENT

Before completing this form, review the requirements of the regulations implementing the Patient Safety and Quality Improvement Act of 2005, which are spelled out in 42 CFR Part 3 (available at www.pso.ahrq.gov), especially sections 3.102(d)(1) and 3.104(b).

The rule requires that a PSO must have entered at least two bona fide contracts within the 24-month period immediately following its initial listing by the Secretary and must have entered at least two bona fide contracts during each sequential

24-month period after the date of its initial listing by the Secretary.

Submit this attestation at least 45 days in advance of the last day of each 24-month period. Advance notification enables the Secretary to harmonize two statutory requirements: to afford the PSO a reasonable opportunity for correction of any deficiency and to ensure that PSOs meet the statutory deadline of 24 months for fulfilling this requirement. The statutory deadline is unambiguous, and contracts entered after midnight of the last day of the PSO’s 24-month assessment period cannot be considered. If the PSO has entered at least two bona fide contracts 45 days before the end of a 24-month assessment period and properly completes and submits this form in a timely manner, no further action by the PSO is necessary during the current 24-month assessment period.

If the PSO reports that it has not yet met the two bona fide contracts requirement, or fails to file the form by that date, the Secretary will issue a notice of a preliminary finding of deficiency and the PSO will be given until midnight of the last day of its 24-month assessment period to meet the two contracts requirement. The issuance of such a notice for this purpose does not change the entity’s status as a PSO during this correction period. If a PSO needs the full 24 months to comply with the requirement, it may submit this completed and signed certification form electronically (in a PDF formatted file) until midnight of the last day of the 24-month assessment period. Failure to submit a certification of compliance with the two contracts requirement by midnight of the 24-month assessment period will trigger the process for revoking the

Secretary’s acceptance of a PSO’s certification and the prompt delisting of the PSO.

CERTIFICATION OF ATTESTATION

The _________________________________(insert name of PSO) was last listed as a PSO by the Secretary on the effective date of_______________________ and this attestation covers the 24 month period from this listing date to _________________________.

During this period the above-named PSO met the above-described bona fide contracts requirement.  YES  NO

I am authorized to complete this form and to certify that all statements are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (United States Code, Title 18, Section 1001).

PSO Authorized Official Printed Name: ___________________________________________­­­­­­­­­­­­­­­­­________________________

PSO Authorized Official Title: ___________________________________________________________________________

PSO Authorized Official Signature: ________________________________________________________________________

Date: _________________________________________________________________________________________________

Burden Statement

Public reporting burden for the collection of information on this complaint form is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201