Form #2 Form #2 Two-Contract Requirement Form

Form Approved


OMB No. 0935-XXXX


Exp. Date XX/XX/20XX

PATIENT SAFETY ORGANIZATION:

TWO BONA FIDE CONTRACTS REQUIREMENT

Before completing this form, please review the requirements of the rule specified in 42 CFR Part 3, especially sections 3.102(d)(1) and 3.104(b). The rule implements the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), which authorizes 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 dealing with PSO operations. The rule and other PSO-related information are available on AHRQ’s PSO Web site at www.pso.ahrq.gov.

The rule requires that a PSO must have at least two bona fide contracts in effect within the 24-month period immediately following its initial listing by the HHS Secretary and must meet the requirement during each sequential 24-month period after the date of its initial listing by the Secretary.

The Secretary must receive this attestation, whether the PSO has met the requirement or not, at least 45 calendar days in advance of the last day of each 24-month period. Advance notification enables the Secretary to harmonize two statutory requirements to: (1) afford the PSO a reasonable opportunity for correction of any deficiency, and (2) ensure the PSO meets 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. A PSO is encouraged to submit the form as soon as the requirement is met.

If the PSO reports that it has not yet met the two bona fide contracts requirement, or fails to file the form by the date referenced above, 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. Failure to submit this form certifying compliance with the two bona fide 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 delisting of the PSO.

Please submit this form to AHRQ’s PSO Office via email, if possible, at [email protected]. To submit a hard copy, please send to: PSO Office, AHRQ, 540 Gaither Road, Rockville, MD 20850.

PART I: ATTESTATION REGARDING TWO BONA FIDE CONTRACTS REQUIREMENT

Insert name of PSO and AHRQ PSO assigned number below:

__________________________________________________________________________________________ was last listed

as a PSO by the Secretary on the effective date of ________________________, and this attestation covers the 24-month period

from __________________ to __________________________.

During this period the PSO met the two bona fide contracts requirement.  YES  NO

PART II: CERTIFICATION OF ATTESTATIONS

I am authorized to complete this form and to certify that all statements are made in good faith and are true, complete, and correct to the best of my knowledge and belief. 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: ___________________________________________________________________________________________________

This completed form is considered public information

Burden Statement

Public reporting burden for the collection of information is estimated to average 15 minutes per response.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

PSO Two Bona Fide Contracts Requirement Page 2 of 2