Form #3 Form #3 PSO Two Bona Fide Contracts Requirement Form

Form Approved

OMB No.: 0935-0143

Exp. Date: ??/??/????

PATIENT SAFETY ORGANIZATION: TWO BONA FIDE CONTRACTS REQUIREMENT
The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), and its implementing regulations in 42 CFR Part 3 (Patient Safety Rule), 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 and Patient Safety Rule dealing with PSO operations. Information related to PSOs is available on AHRQ's PSO Web site at www.pso.ahrq.gov. Please review the Patient Safety Act and Patient Safety Rule, especially sections 3.102(d)(1) and 3.104(b). To remain listed, the Patient Safety Rule requires that a PSO must have two bona fide contracts in effect within each 24-month period after the PSO's initial date of listing. Contracts entered after midnight of the last day of a PSO's 24-month assessment period cannot be counted toward meeting the two contract requirement for that 24-month period. A PSO is also required to provide notice that it has met this requirement by submitting this form once during every 24-month period after its initial date of listing. PSOs are encouraged to submit the form as soon as the requirement is met during each 24-month period. Whether the PSO has met the two contract requirement or not, this form must be received no later than 45 days before the last day of each 24-month assessment period. If the PSO reports that it has not yet met the two bona fide contracts requirement, or fails to file this 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 E-mail, 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
In completing this form, list dates using the following format: MM/DD/YYYY. For a PSO initially listed on 01/22/2012, the first 24-month period would be 01/22/2012 to 01/21/2014, the second period would be 01/22/2014 to 01/21/2016, etc.
(PSO Name) (AHRQ Assigned PSO Number) ___________________________________________________________________, _________________ was initially 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 above-named PSO met the above-described bona fide contracts requirement.	___ Yes	___ No

PART II: CERTIFICATION OF ATTESTATIONS
I am legally authorized to complete this form on behalf of the PSO. The statements on this form 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).
Authorized Official Printed Name
Authorized Official Title
Authorized Official Organization (if different from PSO)
Authorized Official Phone	Authorized Official Fax
Authorized Official Email
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 60 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.

Attachment F – PSO Two Bona Fide Contracts Requirement 2