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Patient Safety Organization Forms

Note: The Department of Health and Human Services (HHS) issued the Patient Safety Rule (PDF file, 450 KB; PDF Help) to implement the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), which authorizes the creation of Patient Safety Organizations (PSOs). The Patient Safety Rule became effective on January 19, 2009.

The Agency for Healthcare Research and Quality (AHRQ) administers the PSO provisions of the Patient Safety Act, and the Office for Civil Rights (OCR) is responsible for interpreting and enforcing the confidentiality protections of the Patient Safety Act and the Patient Safety Rule. AHRQ has prepared a form that an organization must use to certify that it meets the requirements to become listed as a PSO and two forms that a listed PSO must use when certifying compliance with other statutory requirements that are incorporated in the Patient Safety Rule. AHRQ has also prepared a form that a PSO seeking continued listing by the Secretary of Health and Human Services must submit before its period of listing expires (i.e., 3 years from its effective date and time of initial listing). Please note that submitting the PDF version of these forms, either via email or as hard copy, is preferred by AHRQ. For questions about the PSO listing process and form submission, please contact the PSO Office. For AHRQ's consideration and processing, all forms must be signed by the PSO's Authorized Official.

Additionally, AHRQ has prepared an information form that listed PSOs are asked to complete and submit annually to the PSO Privacy Protection Center (PSO PPC), and OCR has provided a PSO complaint form that is available on their Web site.

Form for Entities Seeking PSO Listing:
- PSO Certification for Initial Listing (PDF File, 55 KB; PDF Help)

Forms for Currently Listed PSOs:
- PSO Two Bona Fide Contracts Requirement (PDF File, 28 KB; PDF Help)
- PSO Disclosure Statement (PDF File, 41 KB; PDF Help)
- PSO Certification for Continued Listing (PDF File, 53 KB; PDF Help)

Other Forms:
- PSO Information — available at the PSO PPC Web site.
- PSO Complaint —available at the OCR Web site.