Form 6 Form 6 Attachment H: PSO Change of Listing Information

Attachment J

Form Approved
OMB No. 0935-0143
Exp. Date ?????????

PATIENT SAFETY ORGANIZATION: CHANGE OF LISTING INFORMATION

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), and its implementing regulation, 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.

As required by section 3.102(a)(vi) of the Patient Safety Rule, a PSO must promptly notify the Secretary during its period of listing if there have been any changes in the accuracy of the information submitted for listing, along with the pertinent changes.

Instructions: Please provide the PSO’s number and current PSO name; complete only the sections(s) below that apply to the change(s) in listing information that are the subject of this notification; and, have the completed form signed by the PSO’s Authorized Official. Please note that certain changes may affect your PSO’s attestations in support of the current certification for listing (e.g., if a parent organization is added). The PSO Office will contact you for clarification if necessary.

Please submit this form to AHRQ's PSO Office via e-mail, at pso@ahrq.hhs.gov. To submit a hard copy, please send to: PSO Office, AHRQ, 5600 Fishers Lane, MS 06N100B, Rockville, MD 20857.

PSO Number _____________ Current PSO Name__________________________________________________

***Only fill out the section(s) that apply to the changes in listing information.***

PSO Entity Information

Name

If the PSO is legally doing business under another name, please list it here

Website

Street Address

Mailing Address

Phone Extension (if applicable)

Reason for change(s):

PSO Parent Organization(s) Information

Note: If you are reporting a change of parent organization(s) or a change in organizational structure that affects the PSO, please submit to pso@ahrq.hhs.gov a diagram that illustrates the following entities and their organizational relationships: the PSO, the PSO’s parent organization(s), and any health insurance issuers. Please indicate whether there are any entities in between the parent and the PSO.

Name

If the parent organization is legally doing business under another name, please list it here

Website

Street Address

Phone

Extension (if applicable)

Reason for change(s)

Authorized Official Information

Name

Title

Organization (if different from PSO)

Email

Phone

Extension (if applicable)

Reason for change(s)

Primary Point of Contact Information (if Primary Point of Contact is different from the AO)

Name

Title

Organization (if different from PSO)

Email

Phone

Extension (if applicable)

Reason for change(s)

***This form must be signed and dated by the Authorized Official on record with AHRQ.***

Print name _______________________________________________________________

Signature _______________________________________________________________

Date__________________________________________________________________________________

This completed form is considered public information.

Burden Statement

Public reporting burden for the collection of information is estimated to average 5 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.