Information Collection

Medicare Outpatient Observation Notice

IC 221292 under ICR 202512-0938-009 · OMB 0938-1308.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10611 Medicare Outpatient Observation Notice	Form
Form CMS-10611 MOON Form Medicare Outpatient Observation Notice	Form
Form CMS-10611 MOON Form - Spanish version Medicare Outpatient Observation Notice	Form
Medicare Outpatient Observation Notice_Instructions_2025_Clean_.docx	Instruction
Medicare Outpatient Observation Notice_Instructions_2025_Clean_.docx	Instruction
CMS-10611 MOON Form Medicare Outpatient Observation Notice_2025_Updtd.docx	Form
CMS-10611 MOON Form Medicare Outpatient Observation Notice_2025_Updtd.docx	Form
CMS-10611 MOON Form - Spanish version CMS-10611 MOON Spanish_v508.docx	Form
CMS-10611 MOON Form - Spanish version CMS-10611 MOON Spanish_v508.docx	Form
MOON_Redline.pdf Moon Track Change version	IC Document
MOON_Redline.pdf Moon Track Change version	IC Document
MOON_Instructions_2025_Redline.pdf Moon Instruction Track Change version	IC Document
MOON_Instructions_2025_Redline.pdf Moon Instruction Track Change version	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,817

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,073,991	1,390,769	683,222
Annual IC Time Burden (Hours)	518,498	347,692	170,806
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Moon Track Change version		12/08/2025
Moon Instruction Track Change version		12/08/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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