Items 1 and 2: State Agency and hospice
Name and address of the State Agency, and name and address of the hospice with its CMS Certification Number.
CMS-2802B
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE
- Agency
- CMS
- Revision
- 02/11
- Fillable fields
- 42
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2802B: Request for Validation of Accreditation Survey for Hospice
Form CMS-2802B is listed on the CMS forms page as the Request for Validation of Accreditation Survey for Hospice. The form itself is titled Authorization for State Agency Hospice Validation Survey, from the Centers for Medicare & Medicaid Services (CMS). It is a one-page form, signed by a CMS regional representative, that asks a State survey agency to conduct a validation survey of a hospice. The CMS page lists its OMB number as exempt.
The form names the State Agency and the hospice with its CMS Certification Number, the accrediting organization that currently deems the hospice (ACHC, CHAP, TJC or none), and whether the survey is based on a sample selection or on allegations of significant deficiencies. It then lists the hospice conditions to be surveyed, numbered 418.52 through 418.116, plus the 418.110(d) Life Safety Code standard.
The form says the original goes to the State Survey Agency, with copies to CMSO/SCG/DACS. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-2802B
Item 3: current deeming
Whether the hospice is currently deemed by ACHC, CHAP or TJC, or none. The form says none or more than one may be checked.
Item 4A: sample selection survey
Either a full validation survey within 60 calendar days of the AO's accreditation survey end date, with that scheduled end date, or a mid-cycle validation survey. Two boxes cover an initial accreditation survey.
Item 4B: allegation survey
A survey based on allegations of significant deficiencies that could affect patient health and safety: a potential IJ survey started within 2 working days, or one started within 45 calendar days.
Item 5: areas to be surveyed
Checkboxes for hospice conditions from 418.52 Patient's Rights to 418.116 Compliance with Federal, State and Local Laws and Regulations, plus 418.110(d) Life Safety Code.
Items 6 to 8: signature
Signature of the Regional Representative, the region and the date.
How Form CMS-2802B is completed
- 1
Name the State Agency and hospice
Enter the name and address of the State Agency and of the hospice, with the hospice's CMS Certification Number.
- 2
Mark current deeming
Check ACHC, TJC, CHAP 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 any boxes that apply about an initial accreditation survey. Under B, check one timing option.
- 4
Check the areas to survey
In item 5, the form says to check all for a sample validation survey, or the applicable conditions and, if applicable, the Life Safety Code standard for an allegation survey.
- 5
Sign and route it
The Regional Representative signs and enters the region and date. The form says the original goes to the State Survey Agency, with copies to CMSO/SCG/DACS.
Why fill Form CMS-2802B 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, timing and notice
Where it goes
The bottom of the form says Original To: State Survey Agency, and Copies To: CMSO/SCG/DACS.
Sample survey timing
Option A1 asks for a full validation survey within 60 calendar days of the AO's accreditation survey end date, following the protocols and procedures for a Medicare certification survey.
Allegation survey timing
Option B says to initiate the survey within 2 working days for a potential IJ, or otherwise within 45 calendar days.
Validation packet
The form says the SA completes all validation packet documents listed in Exhibit 63 for any full validation survey.
No advance notice
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-2802
REQUEST FOR VALIDATION OF ACCREDITATION
43 fields, 1 page
CMS-2802C
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
34 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-417
HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE
117 fields, 17 pages
CMS-643
Hospice Survey AND Deficiencies Report
38 fields, 3 pages
Who uses Form CMS-2802B?
The form is completed and signed on the CMS side and sent to a State survey agency.
Official sources and the blank
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Questions about Form CMS-2802B
Who signs Form CMS-2802B?
The form has one signature line, item 6, for the Regional Representative, followed by the region and the date.
Why does the form title differ from the CMS page?
The CMS forms page lists it as the Request for Validation of Accreditation Survey for Hospice. The PDF itself is titled Authorization for State Agency Hospice Validation Survey.
What is the difference between options A and B?
Option A is a validation survey based on a sample selection, either within 60 calendar days of the AO's survey end date or mid-cycle. Option B is based on allegations of significant deficiencies which could affect the health and safety of patients.
How soon does an allegation survey start?
The form gives two choices: initiate within 2 working days for a potential IJ, or initiate within 45 calendar days.
Is the hospice told about the survey in advance?
The form says the SA must not notify the facility or AO in advance of the survey.
Which areas can be surveyed?
Item 5 lists hospice conditions from 418.52 Patient's Rights to 418.116 Compliance with Federal, State and Local Laws and Regulations, plus the 418.110(d) Life Safety Code standard. Sample surveys check all of them.