Information Collection

Medicare Outpatient Observation Notice

IC 221292 under ICR 202212-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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 MOON Form Medicare Outpatient Observation Notice	Form
Form CMS-10611 Moon Form Medicare Outpatient Observation Notice	Form
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_SPANISH.docx	Form

IC Title:

Medicare Outpatient Observation Notice

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10611	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Form	CMS-10611	Yes	Yes	Fillable Printable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	683,222	683,222
Annual IC Time Burden (Hours)	170,806	170,806
Annual IC Cost Burden (Dollars)	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.

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