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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.”

Patient name:

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Patient number:

You’re a hospital outpatient receiving observation services. You are not an inpatient
because:

Being an outpatient may affect what you pay in a hospital:
This means your hospital stay will be billed to Medicare Part B instead of Part A.

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•

When you’re a hospital outpatient, your observation stay is covered under Medicare Part B.

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•

For Part B services, you generally pay:

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•

A This means you’ll have a copayment for each outpatient hospital service you get.
•

•

Your Part B copayments may vary by type of service.

20% ofbe lower or higher than the Medicare-approved amount for most doctor services, after the Part
B Part A inpatient deductible. Your hospital can give you more information about billing.

Observation services may affect coverage and payment of your care after you leave
the hospital:
•

If you need skilled nursing facility (SNF) care after you leave the hospital, Medicare Part A
will only cover SNF care if you’ve had a 3-day minimum, medically necessary, inpatient
hospital stay for a related illness or injury. An inpatient hospital stay begins the day the
hospital admits you as an inpatient based on a doctor’s order and doesn’t include the day

Form CMS 10611-MOON

Expiration 11/30/2025 OMB approval 0938-1308

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(Hospitals may include contact information or logo here)

you’re discharged.
•

If you have Medicaid, a After you leave the hospital, Medicare may not pay if you go to a skilled nursing

You aren’t an inpatient because:

facility.

Questions?
•

For more information about your Medicare Advantage plan or other health plan, Medicaid or

the plan may have different rules for SNF coverage after you leave the hospital. Check
with Medicaid or your plan.

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NOTE: Medicare Part A generally doesn’t cover outpatient hospital services, like an
observation stay. However, Part A will generally cover medically necessary inpatient
services if the hospital admits you as an inpatient based on a doctor’s order. In most cases,
you’ll pay a one-time deductible for all of your inpatient hospital services for the first 60 days
you’re in a hospital.
If you have any questions about your observation services, ask the hospital staff member giving you
this notice or the doctor providing your hospital care. You can also ask to speak with someone from
the hospital’s utilization or discharge planning department.
You can alsocoverage, call 1-800-MEDICARE (1-800-633-4227). TTY users shouldcan call
1-877-486-2048.

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Form CMS 10611-MOON

Expiration 11/30/2025 OMB approval 0938-1308

(Hospitals may include contact information or logo here)

Your costs for medications:
Generally, prescription and over-the-counter drugs, including “self-administered drugs,” you get
in a hospital outpatient setting (like an emergency department) aren’t covered by Part B. “Selfadministered drugs” are drugs you’d normally take on your own. For safety reasons, many
hospitals don’t allow you to take medications brought from home. If you have a Medicare
prescription drug plan (Part D), your plan may help you pay for these drugs. You’ll likely need to
pay out-of- pocket for these drugs and submit a claim to your drug plan for a refund. Contact
your drug plan for more information.
If you’re enrolled in a Medicare Advantage plan (like an HMO or PPO) or other Medicare health
plan (Part C), your costs and coverage may be different. Check with your plan to find out about
coverage for outpatient observation services.
If you’re a Qualified Medicare Beneficiary through your state Medicaid program, you can’t be
billed for Part A or Part B deductibles, coinsurance, and copayments.

Additional Information (Optional):

Please sign

Additional Information (Optional):

Form CMS 10611-MOON

Expiration 11/30/2025xx/xx/20xx OMB approval

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(Hospitals may include contact information or logo here)

Sign below to show you received and understandunderstood this notice.

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Signature of Patient or Representative
Signature of patient or representative

Date

/

Time

Date

You have the right to get Medicare information in an accessible format, like large print, Braillebraille, 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-noticeVisit Medicare.gov/aboutus/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 0938-1308 0953. The time required to complete prepare
and distribute this information collection is estimated to average 1510 minutes per responsenotice, including the time to review instructions, search
existing data resources, gatherselect the data needed, andpreprinted form, complete it and review deliver it to the information collection. beneficiary.
If you have comments concerning the accuracy of the time estimate(s)estimates or suggestions for improving this form, please write to: CMS,
PRA Clearance Officer, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Paid for by the Department of Health & Human Services

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