Form #5 Form #5 Disclosure Statement Form

Form Approved
OMB No. 0935-0143
Exp. Date 12/31/2009

PATIENT SAFETY ORGANIZATION:
DISCLOSURE STATEMENT
Before completing this form, please review the requirements of the rule specified in 42 CFR Part 3, especially sections 3.102(d)(2) and
3.104(c). 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
ands Human Services (HHS) administers the provisions of the Patient Safety Act dealing with PSO operations. The rule and other PSOrelated information are available on AHRQ’s PSO Web site at www.pso.ahrq.gov.
Section 3.102(d)(2)(i) of the rule requires that a PSO fully disclose to the HHS Secretary any financial, contractual, or reporting
relationships the PSO has with a contracting provider(s) and, if applicable, the fact that the PSO is not operated independently,
controlled independently, or managed independently from any contracting provider.
Therefore, a PSO must submit a disclosure statement to the Secretary under the following circumstances:
(a) the PSO has entered into a contract with a provider pursuant to the Patient Safety Act and
(b.1) the PSO has other financial, contractual, or reporting relationships with that contracting provider; or
(b.2) the PSO is not managed independently, controlled independently, or does not operate independently from that contracting
provider.
If a PSO enters into a contract with a provider but neither (b.1) nor (b.2) apply, the PSO is not required to submit a disclosure statement.
Conversely, if (b.1) or (b.2) applies, but the PSO has not entered into a contract with that provider pursuant to the Patient Safety Act, there is
no requirement to submit a disclosure statement.
Please submit this form to AHRQ’s PSO Office via email, if possible, at PSO@ahrq.hhs.gov. To submit a hard copy, please send to:
PSO Office, AHRQ, 540 Gaither Road, Rockville, MD 20850.

Deadlines for Filing a Disclosure Statement
If disclosure is required, the Secretary must receive a disclosure statement no later than 45 calendar days after the date on which the
PSO enters into a contract with the provider. These requirements also apply throughout the period that a contract is effective. If the
circumstances described in (b.1) or (b.2) arise during the contract period, the Secretary must receive a disclosure statement within 45
calendar days.
Whether or not a PSO has filed a disclosure statement with respect to a provider, a disclosure statement is required if: 1) the PSO
enters into new or additional relationships, as described in (b.1), with that provider; or 2) that provider exerts new or additional control, as
described in (b.2), over the PSO’s operation. A PSO is not required to file a subsequent disclosure statement if a previously disclosed
relationship (or provider control) terminates, but the PSO is encouraged to inform the Secretary of such termination.

Content of a Disclosure Statement
A disclosure statement must include two sections. The first section must provide a succinct list of the obligations that exist between the
PSO and the contracting provider – apart from any Patient Safety Act contract(s), which do not need to be listed – that create, or contain
relationships of the type described above in (b.1) or (b.2). In the second section, the PSO must provide a brief explanatory narrative that
meets the requirements described below. The required explanatory narrative enables the PSO to explain, given the relationship(s)
described in the first section of the disclosure statement, why the PSO can “fairly and accurately perform patient safety activities.” The
second section is necessary to enable the Secretary to make the determination required by section 3.104(c)(1) of the rule.

Section 1: Describing the Relationships Between the PSO and the Contracting Provider
Because any arrangements between a PSO and a provider may involve several relationships for which the statute requires disclosure
[summarized in (b.1) and (b.2) above], the PSO should organize the statement as a list of obligations that exist between the PSO and
provider and treat the required disclosures as aspects of each obligation. Each obligation should be described succinctly in a short
paragraph that addresses the required statutory disclosures. As an example, if a PSO conducts two different analyses for this provider,
apart from its Patient Safety Act contract, the PSO would have two different obligations and should include two paragraphs. Each
paragraph would describe one study, in a sentence or two, and note which of the required disclosures apply [summarized in (b.1) and
(b.2) above]. If the provider is an investor in, or owner of, the PSO, that fact should be treated as a separate obligation.

PSO Disclosure Statement

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Content of a Disclosure Statement (continued)
Section 2: Statement Describing How the PSO Can Fairly and Accurately Perform Patient Safety Activities
This statement should also be succinct (1,000 words or less) and address:
•

The policies and procedures the PSO has in place to ensure adherence to objectivity and to existing and evolving professional
analytic standards in the analyses it undertakes; and

•

Any other policies, procedures, or agreements that are in place to ensure that the PSO can fairly and accurately perform patient
safety activities (these should be linked, if appropriate, to the specific relationships and issues of control that are listed in
section 1).
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Please note:
•

If a PSO has no relationships to disclose, no action is required.

•

All disclosure statements, the Secretary’s findings, and any conditions, or actions taken based on these statements, will be made
public to inform potential PSO customers about their options and may be posted on the PSO Web site; the Secretary reserves the
right to exclude information that would be exempt from disclosure under the Freedom of Information Act.

•

If the Secretary discovers a relationship that required disclosure for which a disclosure statement was not filed within the 45-day
reporting period, such failure to file will be treated as a deficiency and may trigger the revocation process described in section 3.108
of the regulation for de-listing a PSO.

DISCLOSURE STATEMENT CERTIFICATION: PSO RELATIONSHIP WITH A CONTRACTING PROVIDER
PSO NAME & ASSIGNED AHRQ PSO NUMBER:

NAME – CONTRACTING PROVIDER(S):

ATTACHMENT:
Please attach a disclosure statement that meets the requirements of section 3.102(d)(2) of the rule that provides both (a) the required
disclosures, and (b) the required explanatory narrative.

Disclosure (check one):
__ New

__ Revision to disclosure statement of __________________________ (fill in date)

I am authorized to complete this form and to submit required attachments on behalf of the PSO. I have attached a statement providing
the required disclosure(s) of relationships with contracting providers. The statements on this form, and in any attachments to it, 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 or in any required attachment can be punished by fine or imprisonment or both (United States Code, Title 18,
Section 1001). I also certify that I will submit a revised disclosure statement to the Secretary within 45 days of any change that renders
this attestation (including descriptive disclosures in attached documents) inaccurate or incomplete. Note: A PSO is not required to file a
subsequent disclosure statement if a previously disclosed relationship (or provider control) terminates, but the PSO is encouraged to
inform the Secretary of such termination.
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 30 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 Disclosure Statement

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