Items 1 and 2: State Agency and HHA
Name and address of the State Agency, and name and address of the home health agency with its CMS Certification Number.
CMS-2802C
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
- Agency
- CMS
- Revision
- 03/19
- Fillable fields
- 34
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2802C: Request for Validation of Accreditation Survey for Home Health Agency
Form CMS-2802C is listed on the CMS forms page as the Request for Validation of Accreditation Survey for Home Health Agency. The form itself is titled Authorization for State Agency Home Health Agency 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 home health agency (HHA). The CMS page lists its OMB number as exempt.
The form names the State Agency and the HHA with its CMS Certification Number, the accrediting organization that currently deems the HHA (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 conditions to be surveyed, numbered 484.40 through 484.115.
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-2802C
Item 3: current deeming
Whether the HHA 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 two working days, or one started within 45 calendar days.
Item 5: areas to be surveyed
Checkboxes for 14 conditions, from 484.40 Release of Patient Identifiable Information to 484.115 Personnel Qualifications. The form says to check all for sample surveys and all applicable conditions for allegation surveys.
Items 6 to 8: signature
Signature of the Regional Representative, the region and the date.
How Form CMS-2802C is completed
- 1
Name the State Agency and HHA
Enter the name and address of the State Agency and of the home health agency, with the HHA's CMS Certification Number.
- 2
Mark current deeming
Check ACHC, CHAP, TJC 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, check all conditions for a sample validation survey, or the applicable conditions 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-2802C 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 two 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-2802B
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE
42 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-1572
HHA SURVEY REPORT
61 fields, 3 pages
Who uses Form CMS-2802C?
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-2802C
Who signs Form CMS-2802C?
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 Home Health Agency. The PDF itself is titled Authorization for State Agency Home Health Agency 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 that could affect the health and safety of patients.
How soon does an allegation survey start?
The form gives two choices: initiate within two working days for a potential IJ, or initiate within 45 calendar days.
Is the home health agency told about the survey in advance?
The form says the SA must NOT notify the facility or AO in advance of the survey.
Which conditions can be surveyed?
Item 5 lists 14 conditions, from 484.40 Release of Patient Identifiable Information through 484.102 Emergency Preparedness to 484.115 Personnel Qualifications. Sample surveys check all of them.