Blackout Date Request Form

​Please note that CMS requires that your onsite survey be unannounced and unscheduled. To accommodate times when your primary contact is out of the office or your office is closed, your facility may request a maximum of 14 total blackout dates during a six month period.  These dates must be requested within two weeks of your application received date.  Requests submitted after your deadline will not be accepted. 

If your facility will be unavailable for longer than 14 days, you must put your application on hold – please send all hold requests to

By submitting this request, you are verifying that you have read and understand the above.