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Blackout Date Request Form

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​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 accreditation@abcop.org

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

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Primary Facility Id *


Primary Facility Name *


Primary Facility Address *


City *


State *


Zip *


Requested Blackout Dates *

Contact Email *


Additional Info

Primary Facility Contact *


Affiliate Address


Affiliate City


Affiliate State


Affiliate Zip