All Pennsylvania-licensed hospitals, ambulatory surgical facilities, abortion facilites, and birthing centers are subject to Act 13 of 2002 reporting requirements. All nursing homes and hospitals are subject to reporting requirements of healthcare-associated infections (HAIs) under Act 52 of 2007. The Authority developed the Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced "PAY-sirs") to facilitate electronic reporting. If you are already registered to participate in PA-PSRS, you can log onto PA-PSRS on its homepage.
 
To facilitate communications between all Pennsylvania-licensed hospitals, ambulatory surgical facilities, abortion facilities, birthing centers, nursing homes and the Authority, each facility should complete and return the attached form designating its primary contact for information related to patient safety. You can also use this form to change or update contact information you previously submitted.

Contact Information Form Submission Instructions:

You can submit the PDF form via mail, fax, or e-mail by clicking the appropriate link below. The mailing address, fax number and e-mail address are located at the bottom of each form. If you prefer to e-mail the form you would first need to save the form as a PDF to your desktop, open your e-mail client, and attach the PDF document from your desktop to the e-mail. * You must have Adobe Reader to fill in the forms on the PDF. An Adobe Reader download is also available below if you currently do not have Adobe Reader.

Adobe Portable Document Format (PDF)
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