Information Collection

Medicare Outpatient Observation Notice

IC 221292 under ICR 201612-0938-011 · OMB 0938-1308.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1308 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10611 Medicare Outpatient Observation Notice	Form
CMS-10611MOONinstructions_07 25 2016 v508.docx	Instruction
CMS-10611 MOON Form CMS-10611MOON_07 25 2016 v508.docx	Form
CMS-10611 MOON Form (Spanish Version) 0938-1308. Medicare Outpatient Observation Notice (MOON) - Spanish Language Version.docx	Form
CMS-10611MOONcrosswalkFR.docx crosswalk	IC Document

IC Title:

Medicare Outpatient Observation Notice

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,142

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,399,999	1,399,999
Annual IC Time Burden (Hours)	350,000	350,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.