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Request For Validation Of Accrediation Survey For Hospital Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Request For Validation Of Accrediation Survey For Hospital, CMS-2802, Official Federal Forms Centers For Medicare And Medicaid Services,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . AND HUMAN SERVICES
DEPARTMENT OF HEALTH . . .
:
CENTERS FOR MEDICARE & MEDICAID SERVICES
Index No.
:
REQUEST FOR VALIDATION OF ACCREDITATIONCalendar No. FOR HOSPITAL
SURVEY
1. NAME AND ADDRESS OF STATE AGENCY
2. NAME AND ADDRESS OF HOSPITAL
:
JUDICIAL SUBPOENA
Plaintiff(s)
-against-
:
:
PROVIDER NUMBER
:
3. HOSPITAL ACCREDITED BY:
4. PLEASE REQUEST COMPLETION OF
Defendant(s)
:
. . . . .I . AOA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I .CMS-2567
. ...
. ...
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5.
6.
JCAHO.
...
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PLEASE DO NOT NOTIFY THE HOSPITAL IN ADVANCE OF YOUR SURVEY.
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THIS VALIDATION IS BASED ON A STATE SELECTION. YORK
THE PEOPLE OF THE SAMPLE OF NEW
THE DATE OF LAST ACCREDITATION SURVEY WAS __________ . PLEASE CONDUCT A FULL VALIDATION SURVEY WITHIN 60 DAYS.
CONFINE THE SURVEY TO THOSE CONDITIONS OF PARTICIPATION FOR WHICH ACCREDITED HOSPITALS ARE DEEMED TO MEET.
TO
THIS VALIDATION IS BASED ON ALLEGATIONS OF SIGNIFICANT DEFICIENCIES WHICH COULD AFFECT THE HEALTH AND SAFETY OF PATIENTS IN
THIS HOSPITAL. PLEASE CONDUCT A SURVEY WITHIN 45 DAYS AFTER THIS REQUEST, FOR THE PURPOSE OF ASCERTAINING WHETHER THE
HOSPITAL MEETS THE CONDITIONS CHECKED.
7. AREAS TO BE SURVEYED (Check all applicable Conditions; enter all applicable Standards)
GREETINGS:
CONDITION(S)
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STANDARDS
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Federal, State and Local Laws(482.11)
__________________________________
,
the Honorable
at the
Court
Governing Bodyof
(482.12)
__________________________________
located at
County
Patient Rights (482.13)
__________________________________
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Quality Assurance (482.21)
__________________________________
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Medical Staff (482.22)
__________________________________
Nursing Services (482.23)
__________________________________
Medical Record Services (482.24)
__________________________________
Pharmaceutical Services (482.25) comply with this subpoena is punishable as a contempt of court and will make you liable to
__________________________________
Your failure to
Radiologic Services (482.26) behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
__________________________________
the party on whose
result of your failure
Laboratory Services (482.27) to comply.
__________________________________
I Fatal Transfusion Reaction
__________________________________
Food and Dietetic Witness,(482.28)
Services Honorable
__________________________________
, one of the Justices of the
Utilization Review (482.30)
__________________________________
Court in
County,
day of
, 20
Physical Environment (482.41)
__________________________________
I LSC
__________________________________
Infection Control (482.42)
__________________________________
(Attorney must sign above and type name below)
Discharge Planning (482.43)
__________________________________
Organ, Tissue, & Eye Procurement (482.45)
Surgical Services (482.51)
Anesthesia Services (482.52)
Nuclear Medicine Services (482.53)
Outpatient Services (482.54)
Emergency Services (482.55)
Rehabilitation Service (482.56)
Respiratory Care Services (482.57)
__________________________________
__________________________________
__________________________________
Attorney(s) for
__________________________________
__________________________________
__________________________________
__________________________________
Office and P.O. Address
__________________________________
A COPY OF THE ALLEGATION IS ENCLOSED. A COPY OF THE ALLEGATION WAS PREVIOUSLY FORWARDED TO THE ACCREDITING AGENCY. THE NAME OF
THE COMPLAINANT SHOULD NOT BE DISCLOSED UNLESS THERE IS SPECIFIC AUTHORIZATION.
8. SIGNATURE OF REGIONAL REPRESENTATIVE
Form CMS-2802 (12/01)
Telephone No.:
9. REGIONFacsimile No.:
E-Mail Address:
Mobile Tel. No.:
ORIGINAL TO: STATE SURVEY AGENCY
COPIES TO: CMS Accreditation Staff
Accreditation Organization
10. DATE
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