Medicare Outpatient Observation Notice

Medicare Outpatient Observation Notice (MOON) (CMS-10611)

Documents and Forms

Document Name Document Type
Form CMS-10611 Medicare Outpatient Observation Notice Form
Medicare Outpatient Observation Notice_Instructions_2025_Clean_.docx Instruction
CMS-10611 MOON Form Medicare Outpatient Observation Notice_2025_Updtd.docx Form
CMS-10611 MOON Form - Spanish version CMS-10611 MOON Spanish_v508.docx Form
MOON_Redline.pdf Moon Track Change version IC Document
MOON_Instructions_2025_Redline.pdf Moon Instruction Track Change version IC Document

Information Collection (IC) Details

IC Title:	Medicare Outpatient Observation Notice	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,817	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

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

Documents for IC

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.