Form CMS-10611 MOON Form

Patient name: Patient number:

Hospital name:

Hospital address:

Medicare Outpatient Observation Notice

Important! You’re getting this notice because your hospital status is “hospital outpatient receiving observation services,” not “hospital inpatient.”

This means your hospital stay will be billed to Medicare Part B instead of Part A.

• When you’re a hospital outpatient, your observation stay is covered under Medicare Part B. This means you’ll have a copayment for each outpatient hospital service you get.

• Your Part B copayments may be lower or higher than the Part A inpatient deductible. Your hospital can give you more information about billing.

• After you leave the hospital, Medicare may not pay if you go to a skilled nursing facility.

You aren’t an inpatient because:

Questions?

For more information about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Form CMS 10611-MOON Expiration xx/xx/20xx OMB approval 0938-xxxx

Additional Information (Optional):

Sign below to show you received and understood this notice.

You have the right to get Medicare information in an accessible format, like large print, braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

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- 0953. The time required to prepare and distribute this collection is 10 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Paid for by the Department of Health & Human Services

Form CMS 10611-MOON Expiration xx/xx/20xx OMB approval 0938-xxxx