Form #2 Form #2 Two Bona Fide Contracts Requirement Form

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

PATIENT SAFETY ORGANIZATION:
TWO BONA FIDE CONTRACTS REQUIREMENT
Before completing this form, please review the requirements of the rule specified in 42 CFR Part 3, especially sections
3.102(d)(1) and 3.104(b). 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 and Human Services (HHS) administers the provisions of the Patient Safety
Act dealing with PSO operations. The rule and other PSO-related information are available on AHRQ’s PSO Web site at
www.pso.ahrq.gov.
The rule requires that a PSO must have at least two bona fide contracts in effect within the 24-month period immediately
following its initial listing by the HHS Secretary and must meet the requirement during each sequential 24-month period
after the date of its initial listing by the Secretary.
The Secretary must receive this attestation, whether the PSO has met the requirement or not, at least 45 calendar days in
advance of the last day of each 24-month period. Advance notification enables the Secretary to harmonize two statutory
requirements to: (1) afford the PSO a reasonable opportunity for correction of any deficiency, and (2) ensure the PSO
meets the statutory deadline of 24 months for fulfilling this requirement. The statutory deadline is unambiguous, and
contracts entered after midnight of the last day of the PSO’s 24-month assessment period cannot be considered. A PSO
is encouraged to submit the form as soon as the requirement is met.
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 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.

PART I:

ATTESTATION REGARDING TWO BONA FIDE CONTRACTS REQUIREMENT

Insert PSO name and AHRQ-assigned PSO number below:
__________________________________________________________________________________________ was last 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 PSO met the two bona fide contracts requirement.

__ YES

__ NO

PSO Two Bona Fide Contracts Requirement

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PART II:

CERTIFICATION OF ATTESTATIONS

I am authorized to complete this form and certify that all statements 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).

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 15 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 Two Bona Fide Contracts Requirement

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