Items 1 and 2: agency and hospital
Name and address of the state agency, and name and address of the critical access hospital with its CMS Certification Number.
CMS-2802E
REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
- Agency
- CMS
- Revision
- 02/11
- Fillable fields
- 35
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2802E: Authorization for State Agency CAH Validation Survey
Form CMS-2802E is the Authorization for State Agency Critical Access Hospital (CAH) Validation Survey from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The CMS forms page lists it as Request for Validation of Accreditation for Critical Access Hospital Survey, with O.M.B. # EXEMPT. It names a state agency and a critical access hospital, records which accrediting organization currently deems the CAH, and sets out the kind of validation survey to conduct.
The form gives two bases for the survey: a sample selection, either within 60 calendar days of an accreditation survey end date or as a mid-cycle survey, or allegations of significant deficiencies that could affect the health and safety of patients. It then lists the areas to be surveyed by regulation section, from 485.608 to 485.647, including the Life Safety Code standard at 485.623(d).
The form is signed by a regional representative, with the region and date. 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-2802E
Item 3: current deeming
Which accrediting organization currently deems the CAH: AOA/HFAP, TJC or none. The form says none or more than one may be checked.
Item 4A: sample selection survey
Check 1 or 2, not both: a full validation survey within 60 calendar days of the named AO's accreditation survey end date, with initial accreditation boxes, or a mid-cycle validation survey.
Item 4B: allegation survey
A survey based on allegations of significant deficiencies that could affect patient health and safety, with one choice: potential IJ, initiate survey within 2 working days, or initiate survey within 45 calendar days.
Item 5: areas to be surveyed
Checkboxes for regulation sections 485.608 through 485.647, such as emergency services, number of beds and length of stay, physical plant and environment with the Life Safety Code, clinical records and swing-beds.
Items 6 to 8: signature
Signature of the regional representative, the region and the date. The footer says the original goes to the state survey agency and copies to CMSO/SCG/DACS.
How to fill out Form CMS-2802E
- 1
Name the agency and hospital
Enter the state agency's name and address in item 1, and the CAH's name, address and CMS Certification Number in item 2.
- 2
Mark the current deeming status
In item 3, check AOA/HFAP, TJC or NONE. The form says none or more than one may be checked.
- 3
Choose the survey basis
Check A or B in item 4, not both. Under A, check 1 or 2 and, for option 1, enter the AO name and the scheduled accreditation survey end date. Under B, check one of the two timing options.
- 4
Pick the areas to survey
For sample validation surveys the form says to check all areas. For allegation surveys, it says to check all applicable conditions and, if applicable, the Life Safety Code standard.
- 5
Sign, date and distribute
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-2802E 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
Where it goes and survey timing
Where it goes
The footer says the original goes to the state survey agency and copies go to CMSO/SCG/DACS.
Survey timing
The form lists a full validation survey within 60 calendar days of the accreditation survey end date for option 4A1, and for allegations either within 2 working days for a potential IJ or 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.
Advance notice
The form says the SA must not notify the facility or AO in advance of the survey.
OMB status
The PDF prints no OMB number. The CMS page lists O.M.B. # EXEMPT and a revision date of 2011-02-01.
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-2802D
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
35 fields, 1 page
CMS-2802F
Authorization for State Agency Psychiatric Hospital Validation Survey
42 fields, 1 page
CMS-2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
22 fields, 5 pages
Who uses Form CMS-2802E?
The form is an authorization between CMS and a state survey agency about a specific critical access hospital.
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Questions about Form CMS-2802E
Who signs Form CMS-2802E?
Item 6 is the signature of the regional representative, who also enters the region in item 7 and the date in item 8.
What is the difference between items 4A and 4B?
Item 4A is a validation survey based on a sample selection, either within 60 calendar days of an accreditation survey end date or mid-cycle. 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 an allegation survey start?
Item 4B offers two choices: potential IJ, initiate survey within 2 working days, or initiate survey within 45 calendar days.
Is the hospital told about the survey in advance?
The form says the SA must not notify the facility or AO in advance of the survey.
Where does Form CMS-2802E go?
The footer says the original goes to the state survey agency, with copies to CMSO/SCG/DACS.
Why does the CMS page show a different title?
The PDF is titled Authorization for State Agency Critical Access Hospital (CAH) Validation Survey. The CMS forms page lists the same form number as Request for Validation of Accreditation for Critical Access Hospital Survey.