Items 1 and 2: State Agency and ASC
The name and address of the State Agency, and the name, address and CMS Certification Number of the ambulatory surgical center.
CMS-2802D
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
- Agency
- CMS
- Revision
- 02/11
- Fillable fields
- 35
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2802D: Authorization for State Agency ASC Validation Survey
Form CMS-2802D is listed by the Centers for Medicare & Medicaid Services as the Request for Validation of Accreditation Survey for Ambulatory Surgical Center. The form itself is titled Authorization for State Agency Ambulatory Surgical Center (ASC) Validation Survey. It is a one-page form signed by a CMS regional representative. The routing line at the bottom sends the original to the State survey agency, with copies to CMSO/SGC/DACS. The CMS page lists its O.M.B. number as exempt.
The form names the State Agency and the ASC with its CMS Certification Number, records which accrediting organizations currently deem the ASC, and says whether the validation survey is based on a sample selection or on allegations of significant deficiencies that could affect the health and safety of patients. It then lists the areas to be surveyed by section number, from 416.25 Basic Requirements to 416.52 Patient Admission, Assessment & Discharge, including the 416.44(b) Life Safety Code standard.
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What's on Form CMS-2802D
Item 3: Current deeming
Which accrediting organizations currently deem the ASC: AAAASF, AAAHC, AOA/HFAP, TJC or None.
Item 4A: Sample selection survey
Either a full validation survey within 60 calendar days of the named AO's accreditation survey end date, with the scheduled end date and boxes for initial accreditation surveys, or a mid-cycle validation survey.
Item 4B: Allegation survey
A survey based on allegations of significant deficiencies, with a choice of potential IJ (initiate within 2 working days) or initiate within 45 calendar days.
Item 5: Areas to be surveyed
Checkboxes for each listed area, such as governing body and management, surgical services, infection control, patient rights and the Life Safety Code standard.
Items 6 to 8: Signature
The signature of the regional representative, the region and the date.
How to fill out Form CMS-2802D
- 1
Name the State Agency and ASC
Enter both names and addresses in items 1 and 2, with the ASC's CMS Certification Number.
- 2
Record the deeming status
Check each accrediting organization that currently deems the ASC in item 3, or None.
- 3
Choose 4A or 4B
The form says to check A or B, not both. Under 4A, it says to check 1 or 2, not both. Under 4B, check one of the two timing options.
- 4
Mark the areas to be surveyed
The form says to check all areas for sample validation surveys, and for allegation surveys all applicable conditions plus the Life Safety Code standard if applicable.
- 5
Sign and route it
The regional representative signs item 6 and enters the region and date. The routing line sends the original to the State survey agency and copies to CMSO/SGC/DACS.
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Routing, timeframes and what the form says
Routing
The footer reads Original to: State Survey Agency. Copies to: CMSO/SGC/DACS.
Survey timeframes
Item 4A1 asks for a full validation survey within 60 calendar days of the AO's accreditation survey end date. Item 4B gives 2 working days for a potential IJ, or 45 calendar days.
No advance notice
Printed under item 4B, the form says the SA must not notify the facility or AO in advance of the survey.
Validation packet
The form says the SA must complete all validation packet documents listed in Exhibit 63 for any full validation survey.
OMB status
The CMS page lists the O.M.B. number as exempt and the revision date as 2011-02-01, with no special instructions.
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-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-377
AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE
32 fields, 3 pages
CMS-370
HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER
10 fields, 2 pages
Who uses Form CMS-2802D?
This is a one-page CMS survey authorization, not an application from a facility.
Official sources and the blank
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Questions about Form CMS-2802D
Who signs Form CMS-2802D?
Item 6 is the signature of the regional representative. Item 7 is the region and item 8 the date.
What is the difference between items 4A and 4B?
Item 4A is a validation survey based on a sample selection, either a full survey after an accreditation survey or a mid-cycle survey. Item 4B is a survey based on allegations of significant deficiencies that could affect the health and safety of patients. The form says to check A or B, not both.
How soon does the validation survey take place?
The form lists within 60 calendar days of the AO's accreditation survey end date for item 4A1. For allegation surveys it gives 2 working days for a potential IJ, or 45 calendar days.
Is the ASC told about the survey in advance?
Printed under item 4B, the form says the SA must not notify the facility or AO in advance of the survey.
Which accrediting organizations are on the form?
Item 3 lists AAAASF, AAAHC, AOA/HFAP and TJC, plus None. The form says none or more than one may be checked.
Does Form CMS-2802D have an OMB number?
No. The CMS page lists its O.M.B. number as exempt.