MCSN_English_Instructions_drafttoOSORA_508

Notice Instructions: Medicare Change of Status Notice
Page 1 of the Medicare Change of Status Notice (MCSN)
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 number:
The Patient number may be a unique medical record or other provider-issued
identification number. It may not be the Social Security Number, or any
Medicare-issued number assigned to the beneficiary such as the MBI
(Medicare Beneficiary Identifier) or HICN (Health Insurance Claim Number).

Page 2 of the MCSN
Call the QIO listed on Page 1:
Insert the appropriate QIO name and telephone number for the state in which the
hospital giving the MCSN is located.

Oral Explanation:
When delivering the MCSN, hospitals and CAHs are required to explain the notice
and its content and answer all beneficiary questions to the best of their ability.

Instructions CMS-10868

OMB expiration: xx-xx-

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.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-1308. The time required to complete this information collection is estimated to average 15
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Instructions CMS-10868

OMB expiration: xx-xx-