Information Collection

Medicare Outpatient Observation Notice

IC 221292 under ICR 202208-0938-020 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10611 Medicare Outpatient Observation Notice Form
CMS_10611_MOONinstructions_2022_OSORA.pdf Instruction
CMS_10611_MOONinstructions_2022_OSORA.pdf Instruction
CMS-10611 MOON Form CMS-10611 MOON_2022_v508_OSORA.pdf Form
CMS-10611 MOON Form CMS-10611 MOON_2022_v508_OSORA.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10611	MOON Form	CMS-10611 MOON_2022_v508_OSORA.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS_10611_MOONinstructions_2022_OSORA.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,312	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	683,222	-262,987	946,209
Annual IC Time Burden (Hours)	170,806	-65,746	236,552
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.