CMS_10065_IMinstructions_2022_OSORA

Form Instructions for the Important Message from Medicare
(IM) CMS-10065

Page 1 of the Important Message from Medicare (IM)

Heading: Insert contact information here: The name, address and telephone number
of the hospital or Medicare health plan that delivers the notice must appear above the
title of the form. The entity’s registered logo is not required, but may be used.
Patient Name: Fill in the beneficiary’s/enrollee’s first and last name.
Patient number: The Patient number may be a unique medical record or other
provider-issued identification number. It may not be the Social Security Number, HICN
or any other Medicare number issued to the beneficiary such as the MBI (Medicare
Beneficiary Identifier).
Bullet 3: Insert the name and toll-free number of the Quality Improvement
Organization (QIO) for the state in which the hospital is located.

Page 2 of the Important Message from Medicare

Bullet 4: Insert the name and toll-free number of the QIO for the state in which the
hospital is located.
Bullet 6 (Plans only): The plan’s name and contact information must be displayed
here for the enrollee’s use in case an expedited appeal is requested or in the event the
enrollee or QIO seeks the plan’s identification.
Additional information (Optional): This section provides space for additional pertinent
information that may be useful to the beneficiary/enrollee. It may not be used as a
Detailed Notice of Discharge, even if facts pertinent to the termination decision are
provided.
Signature line: Have the beneficiary/enrollee or representative sign the notice to
indicate that he or she has received it and understands its contents.
Date/Time: Have the beneficiary/enrollee or representative write the date and time that
he or she signed the notice. If the document is delivered, but the enrollee or the
representative refuses to sign on the delivery date, annotate the IM to indicate the date
and time that the notice was delivered.

Form CMS 10065-IM instructions (Exp. XX/XX/20XX)

OMB approval 0938-1019