CMS_10611_MOONinstructions_2022_OSORA

Notice Instructions: Medicare Outpatient Observation Notice

Page 1 of the Medicare Outpatient Observation Notice (MOON)
The following blanks must be completed by the hospital. Information inserted may be
typed or legibly hand-written in 12-point font or the equivalent.
Patient Name:
Fill in the patient’s full name or attach patient label.
Patient ID number:
Fill in an ID number that identifies this patient, such as a medical record
number or the patient’s birthdate or attach a patient label. This number
should not be the patient’s social security number.
“You’re a hospital outpatient receiving observation services. You are not an
inpatient because:”
Fill in the specific reason the patient is in an outpatient, rather than an
inpatient stay.

Page 2 of the MOON
Additional Information:
This may include, but is not limited to, Accountable Care Organization (ACO)
information, notation that a beneficiary refused to sign the notice, hospital
waivers of the beneficiary’s responsibility for the cost of self-administered
drugs, Part A cost sharing responsibilities if the beneficiary is subsequently
admitted as an inpatient, physician name, specific information for contacting
hospital staff, or additional information that may be required under applicable
state law.
Hospitals may attach additional pages to this notice if more space is needed for
this section.
Oral Explanation:
When delivering the MOON, hospitals and CAHs are required to explain the
notice and its content, document that an oral explanation was provided and
answer all beneficiary questions to the best of their ability.

Instructions CMS-10611

OMB expiration: xx-xx-20xx

Signature of Patient or Representative:
Have the patient or representative sign the notice to indicate that he or she
has received it and understands its contents. If a representative’s signature
is not legible, print the representative’s name by the signature.
Date/Time: Have the patient or representative place the date and time that he or she
signed the notice.

Instructions CMS-10611

OMB expiration: xx-xx-20xx