Crosswalk

CROSSWALK CHANGES TO CMS-10611 MOON
Change
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Form

Change

Updated form so that it adheres to CMS' current
forms formatting by adding the Department of
Health and Human Services logo and changing
CMS-10611 font.

Create space at top of form for fill areas for
patient name, patient number, hospital name and
CMS-10611 hospital address
Created a header flagged as "Important!" This
briefly explains the purpose of the notice which
helps the patient identify what it's for
CMS-10611 immediately.
Revised all bullets on page 1 to shorten and
consolidate the information. Working from
standards used across the agency, the Office of
Communications helped MEAG to revise the
information and phrase it in plain language. The
notice retains only the information that the patient
CMS-10611 will be able to use immediately.

Move the hospital-fillable section from the top of
CMS-10611 the page to appear after the informational bullets.

Current
Location

Reason

All over

CMS Office of Communication prefers all forms to
have a similar appearance so that the form is
easily recognized as a CMS form

Top of page 1

Previous version required hospitals to insert the
hospital name and any other hospital information
at the top of the page but there was no indicator
line identifying what that information was. The
revision has the patient and hospital names
identified and located together for easy reference.

Page 1

Add header flagged as "Important!" to highlight
the purpose of the notice and make the statement
brief.

Page 1

Consolidate and clarify information that is
relevant. Removed information that might not
apply or could cause confusion.

Page 1

Move the space for the hospital to insert free text
explaining "You aren’t an inpatient because:" After
the notice lists some basic information on the
difference between inpatient and outpatient
receiving observation services, the hospital can
insert relevant details specific to the patient's
circumstances in this free text field.