Items 1 and 2: State agency and hospital
Name and address of the State agency, and name and address of the hospital with its CMS certification number.
CMS-2802
REQUEST FOR VALIDATION OF ACCREDITATION
- Agency
- CMS
- Revision
- 02/11
- Fillable fields
- 43
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2802: Authorization for State Agency Hospital Validation Survey
Form CMS-2802 is listed on the CMS forms page as the Request for Validation of Accreditation. The form itself is titled Authorization for State Agency Hospital Validation Survey, from the Centers for Medicare & Medicaid Services (CMS). It is a one-page form, signed by a CMS regional representative, that names a State agency and a hospital and asks for a validation survey of that hospital.
The form records which accrediting organization currently deems the hospital (TJC, DNV, AOA/HFAP or none), and whether the survey is based on a sample selection or on allegations of significant deficiencies which could affect the health and safety of patients. It then lists the hospital conditions to be surveyed, numbered 482.11 through 482.57, plus the 482.41(b) Life Safety Code standard.
The footer says the original goes to the State survey agency, with copies to CMCS/SCG/DACS. The CMS page lists the OMB number as exempt. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-2802
Item 3: deeming status
Boxes for TJC, DNV, AOA/HFAP and NONE. None or more than one may be checked.
Item 4A: sample selection
Box 1 asks for a full validation survey within 60 calendar days of the named AO's accreditation survey end date, with the scheduled end date and two initial accreditation survey boxes. Box 2 is a mid-cycle validation survey.
Item 4B: allegations
For allegations of significant deficiencies, a choice between a potential IJ, with the survey initiated within 2 working days, or a survey initiated within 45 calendar days.
Item 5: areas to be surveyed
Checkboxes for conditions from 482.11 federal, State and local laws to 482.57 respiratory care services, including governing body, nursing, infection control and discharge planning, plus 482.41(b) Life Safety Code.
Items 6 to 8: signature, region and date
Signature of the regional representative, the region and the date.
How Form CMS-2802 is filled out
- 1
Name the agency and hospital
Enter the State agency's name and address, the hospital's name and address, and its CMS certification number.
- 2
Mark the deeming status
Check TJC, DNV, AOA/HFAP or NONE in item 3. The form allows none or more than one.
- 3
Choose the survey basis
The form says to check A or B, not both. Under A, check 1 or 2, not both, and for box 1 enter the AO name and the scheduled end date of the accreditation survey.
- 4
Set the timing for allegations
Under B, check one: potential IJ, initiate survey within 2 working days, or initiate survey within 45 calendar days.
- 5
Check the areas to survey
The form says to check all areas for sample validation surveys, and for allegation surveys all applicable conditions and, if applicable, the Life Safety Code standard.
- 6
Sign and route
The regional representative signs and adds the region and date. The footer routes the original to the State survey agency and copies to CMCS/SCG/DACS.
Why fill Form CMS-2802 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Routing and what the form says
Where it goes
The footer says original to the State survey agency, copies to CMCS/SCG/DACS. No mailing address is printed.
Initial accreditation surveys
Under item 4A box 1, the form has boxes for an initial accreditation survey of a currently participating, non-deemed facility, and for an initial accreditation survey for this AO when the hospital is currently deemed.
Validation packet
Under item 4A, the form says the SA must complete all validation packet documents listed in Exhibit 63 for any full validation survey.
No advance notice
Under item 4B, the form says the SA must not notify the facility or AO in advance of the survey.
OMB status
The CMS page lists the OMB number as EXEMPT. No OMB number or expiration date is printed on the form.
Related forms
CMS-2802B
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE
42 fields, 1 page
CMS-2802C
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
34 fields, 1 page
CMS-2802D
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
35 fields, 1 page
CMS-2802E
REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
35 fields, 1 page
CMS-2802F
Authorization for State Agency Psychiatric Hospital Validation Survey
42 fields, 1 page
CMS-2786T
Fire Safety Evaluation System - Health Care 2012 Life Safety Code
187 fields, 7 pages
Who uses Form CMS-2802?
The form is addressed to a State agency about one hospital and signed by a CMS regional representative.
Official sources and the blank
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Questions about Form CMS-2802
What is Form CMS-2802?
The form is titled Authorization for State Agency Hospital Validation Survey, and the CMS page lists it as the Request for Validation of Accreditation. It names a State agency and a hospital and asks for a validation survey of that hospital.
What kinds of validation survey does the form cover?
Item 4A is a survey based on a sample selection, either a full validation survey or a mid-cycle validation survey. Item 4B is a survey based on allegations of significant deficiencies which could affect the health and safety of patients.
Can both A and B be checked?
No. The form says to check A or B and not both, and under A to check 1 or 2 and not both.
How soon does the form say the survey starts?
For a sample survey under 4A box 1, within 60 calendar days of the AO accreditation survey end date. For an allegation survey under 4B, within 2 working days for a potential IJ, or within 45 calendar days.
Is the hospital told before the survey?
Under item 4B, the form says the SA must not notify the facility or AO in advance of the survey.
Which accrediting organizations does item 3 list?
TJC, DNV and AOA/HFAP, plus a NONE box. The form says none or more than one may be checked.
Who signs Form CMS-2802?
Item 6 is the signature of the regional representative, with the region and date in items 7 and 8.