Medicare Outpatient Observation Notice

(CMS-10611) Medicare Outpatient Observation Notice (MOON)

OMB: 0938-1308

IC ID: 221292

Documents and Forms
Document Name
Document Type
Form
Instruction
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Medicare Outpatient Observation Notice
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10611 MOON Form (Spanish Version) 0938-1308. Medicare Outpatient Observation Notice (MOON) - Spanish Language Version.docx Yes Yes Fillable Fileable
Form CMS-10611 MOON Form CMS-10611MOON_07 25 2016 v508.docx Yes Yes Fillable Fileable
Instruction CMS-10611MOONinstructions_07 25 2016 v508.docx Yes Yes Fillable Fileable

Health Health Care Services

 

6,142 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,399,999 0 0 0 0 1,399,999
Annual IC Time Burden (Hours) 350,000 0 0 0 0 350,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
crosswalk CMS-10611MOONcrosswalkFR.docx 08/03/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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