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

Attachment G

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 regulation 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 website at www.pso.ahrq.gov. Please review the Patient Safety Act and Patient Safety Rule, especially the definition of bona fide contract in section 3.20 and sections 3.102(d)(1) and 3.104(b) of the Patient Safety Rule. To remain listed, a PSO must comply with all of the Patient Safety Rule’s requirements, including the requirement to have two bona fide contracts in effect for the purpose of receiving and reviewing patient safety work product (PSWP), within each 24-month period after the PSO's initial date of listing. Contracts entered into 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. Do not submit copies of the contracts with this form unless requested by AHRQ. Whether the PSO has met the minimum 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 required date, the Secretary will issue a notice of a preliminary finding of deficiency, and the PSO will be given a correction period until midnight of the last day of its 24-month assessment period to meet the minimum contract 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 last day 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, at pso@ahrq.hhs.gov. To submit a hard copy, please send to: PSO Office, AHRQ, 5600 Fishers Lane, MS 06N100B, Rockville, MD 20857. This form must be signed by the Authorized Official.
PART I: ATTESTATION REGARDING TWO BONA FIDE CONTRACTS REQUIREMENT
In completing this attestation, use the following format for dates: MM/DD/YYYY. For a PSO initially listed on 01/22/2014, the first 24-month period would be 01/22/2014 to 01/21/2016, the second period would be 01/22/2016 to 01/21/2018, 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 had two bona fide contracts, each of a reasonable period of time, each with a different provider, each for the purpose of receiving and reviewing PSWP.		___ 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 Information
Name
Title
Organization (if different from PSO)
Phone	Extension (if applicable)
***This form must be signed and dated by the Authorized Official on record with AHRQ.***
Email
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, 5600 Fishers Lane, MS 06N100B, Rockville, MD 20857.