Information Collection

Medicare Outpatient Observation Notice

IC 221292 under ICR 201911-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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) CMS-10611 MOON Spanish_v508.pdf	Form

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	CMS-10611MOON_07 25 2016 v508.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10611MOONinstructions_07 25 2016 v508.docx	Yes	Yes	Fillable Fileable
Form	CMS-10611	Moon Form (Spanish Version)	CMS-10611 MOON Spanish_v508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,373

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	946,209	-453,790	1,399,999
Annual IC Time Burden (Hours)	236,552	-113,448	350,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.