When an entity seeks listing as a PSO, it must identify an individual with authority to make commitments on behalf of the entity – referred to as “Authorized Official” or “AO” – to complete certain requirements for listing. See section 3.102(a) and the AHRQ guide, “What is the Role of the PSO Authorized Official?”
I am legally authorized to complete this form on behalf of the entity seeking listing as a PSO. The statements on this form, and any submitted attachments or supplements 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, attachments or supplements to it, can be punished by fine or imprisonment or both (United States Code, Title 18, Section 1001).
I understand that, if during the period of listing there are any changes to the accuracy of the listing information, or if there are any changes in the contact information, the PSO must notify AHRQ by submitting a Change of Listing Information form, or by contacting AHRQ’s PSO Office via email at email@example.com or calling toll free at (866) 403-3697 or (866) 438-7231 (TTY).
***This form must be signed and dated by the Authorized Official on record with AHRQ.***