Items 1 and 2: State agency and hospital
Name and address of the State agency, and name and address of the psychiatric hospital with its CMS certification number.
CMS-2802F
Authorization for State Agency Psychiatric Hospital Validation Survey
- Agency
- CMS
- Revision
- 11/11
- Fillable fields
- 42
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2802F: Authorization for State Agency Psychiatric Hospital Validation Survey
Form CMS-2802F, Authorization for State Agency Psychiatric Hospital Validation Survey, is a one-page Centers for Medicare & Medicaid Services form. It names a State agency and a psychiatric hospital and asks the State agency to conduct a validation survey of that hospital.
The form records whether the hospital is currently deemed by TJC or by 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 areas to be surveyed by section of 42 CFR 482, with the region and date at the bottom. The original goes to the State survey agency, with copies to OCSQ/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-2802F
Item 3: deeming status
Two boxes for whether the hospital is currently deemed by TJC or by none.
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 an initial accreditation survey box. Box 2 is a mid-cycle validation survey.
Item 4B: allegations
A choice between a potential IJ, with the survey started within 2 working days, or a survey started within 45 calendar days.
Item 5: areas to be surveyed
Checkboxes for sections of 42 CFR 482, from 482.60(b) compliance with the conditions of participation to 482.41(b) Life Safety Code, 482.61 medical records and 482.62 special staff requirements for psych hospitals.
Items 7 and 8: region and date
The region and the date, at the bottom of the form. The form has no item 6.
How Form CMS-2802F is filled out
- 1
Name the agency and hospital
Enter the State agency's name and address, the psychiatric hospital's name and address, and its CMS certification number.
- 2
Mark the deeming status
Check TJC or NONE in item 3.
- 3
Choose the survey basis
The form says to check A or B, not both. Under A, check 1 or 2, not both, and fill in the AO name and scheduled accreditation survey end date for box 1.
- 4
Set the timing
For an allegation survey under B, check one: potential IJ, initiate within 2 working days, or initiate 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
Add region and date
Fill in the region and date. The footer routes the original to the State survey agency and copies to OCSQ/SCG/DACS.
Why fill Form CMS-2802F 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 OCSQ/SCG/DACS. No mailing address is printed.
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 for Form CMS-2802F as Exempt. The form itself prints no OMB number.
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-2802E
REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
35 fields, 1 page
CMS-437
PSYCHIATRIC UNIT CRITERIA WORKSHEET
266 fields, 8 pages
Who uses Form CMS-2802F?
The form is addressed to a State agency about one psychiatric hospital.
Official sources and the blank
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Questions about Form CMS-2802F
What is Form CMS-2802F?
It is the Authorization for State Agency Psychiatric Hospital Validation Survey. It names a State agency and a psychiatric hospital and asks the State agency to conduct a validation survey.
What kinds of validation survey does the form cover?
Item 4A is a survey based on a sample selection, either full or mid-cycle. 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.
Who receives copies of the form?
The footer says the original goes to the State survey agency and copies go to OCSQ/SCG/DACS.