Medicare Outpatient Observation Notice

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

Documents and Forms

Document Name Document Type
Form CMS-10611 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

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	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
Form	CMS-10611	Moon Form	CMS-10611 MOON_2022_SPANISH.docx	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 %

	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

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.