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Medicare Outpatient Observation Notice

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

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Medicare Outpatient Observation Notice
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10611 MOON Form Medicare Outpatient Observation Notice_2025_Updtd.docx Yes Yes Fillable Fileable
Instruction Medicare Outpatient Observation Notice_Instructions_2025_Clean_.docx Yes Yes Fillable Fileable
Form CMS-10611 MOON Form - Spanish version CMS-10611 MOON Spanish_v508.docx Yes Yes Fillable Fileable

Health Health Care Services

 

5,817 0
   
Private Sector Businesses or other for-profits
 
   0 %

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

Title Document Date Uploaded
Moon Track Change version MOON_Redline.pdf 12/08/2025
Moon Instruction Track Change version MOON_Instructions_2025_Redline.pdf 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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