Medicare Outpatient Observation Notice

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.