Moon Instruction Track Change version

Notice Instructions: Medicare Outpatient Observation Notice
Page 1 of the Medicare Outpatient Observation Notice (MOON)
The following blanks must be completed by the hospital. Information inserted may be typed or
legibly hand-written in 12-point font or the equivalent.
Formatted: Font: 11 pt

Patient Name:

Formatted: Normal, Space Before: 0 pt

Fill in the patient’s full name or attach patient label.

Formatted: Indent: Left: 0"

Patient ID number:

Formatted: Indent: Left: 0"

The Patient number may be a unique medical record or other provider-issued identification
number. It may not be the Social Security Number, HICN or any other Medicare number
issued to the beneficiary such as the MBI (Medicare Beneficiary Identifier).

Formatted: Indent: Left: 0"

Hospital Name:

Formatted: Font: 12 pt, Underline

Hospital Address:

Formatted: Font: 12 pt

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

Formatted: Indent: Left: 0"

Fill in the specific reason(s) the patient is in an outpatient, rather than an inpatient stay.

Formatted: Indent: Left: 0"

Page 2 of the MOON
Additional Information:
This may include, but is not limited to, Accountable Care Organization (ACO)
information, notation that a beneficiary refused to sign the notice, hospital waivers
of the beneficiary’s responsibility for the cost of self-administered drugs, Part A
cost sharing responsibilities if the beneficiary is subsequently admitted as an
inpatient, physician name, specific information for contacting hospital staff, or
additional information that may be required under applicable state law.
Hospitals may attach additional pages to this notice if more space is needed for
this section.

Oral Explanation:
When delivering the MOON, hospitals and CAHs are required to explain the notice
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and its content, document that an oral explanation was provided and answer all
beneficiary questions to the best of their ability.

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Signature of Patient or Representative:
Have the patient or representative sign the notice to indicate that he or she has
received it and understands its contents. If a representative’s signature is not
legible, print the representative’s name by the signature.

Date/Time:
Have the patient or representative place the date and time that he or she signed
the notice.

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. The time required to complete this information collection is estimated to average 15
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Instructions CMS-10611

OMB expiration: XX11-XX30-