Medicare Outpatient Observation Notice

Notice Instructions: Medicare Outpatient Observation Notice (MOON)
Completing the Notice
Page 1 of the Medicare Outpatient Observation Notice (MOON)
A. Header
Hospitals must display “Department of Health & Human Services, Centers for Medicare &
Medicaid Services” and the OMB number.
The following blanks must be completed by the hospital. Information inserted by hospitals
in the blank spaces on the MOON may be typed or legibly hand-written in 12-point font or
the equivalent. When documenting time on this notice, hospitals must use military time or
indicate a.m. or p.m. Hospitals may also use a patient label on the notice that includes some
of the following information:
Patient Name: Fill in the patient’s full name.
Patient ID number: Fill in an ID number that identifies this patient, such as a medical
record number or the patient’s birthdate. This number should not be the social security
number.
Physician: Fill in the name of the patient’s attending physician for this hospital visit.
Date: Fill in the date on which the MOON is given to the beneficiary.
Time: Fill in the time when the MOON is given to the beneficiary.
B. Body of the Notice
The hospital must complete the 3 blank fields in the sentence directly under the title of the
notice.
“On [Date
] at [Time], you began getting observation services at
[Hospital
Name].”
Date: Fill in the date on which observation services started for the beneficiary.
Time: Fill in the time when observation services began for the beneficiary.
Hospital Name: Hospitals may preprint or otherwise insert the name of the hospital
facility.
Page 2 of the Hospital Observation Notice
Header: When giving the notice, if the MOON is printed on 2 separate pages, the hospital
must fill in the patient name and identification number in the header area on page 2 or use a
patient label. If the MOON is given to the beneficiary as a 1 page document printed on the
front and back, the hospital isn’t required to fill in the patient name and identification number
fields on page 2.

Additional Information: Hospitals may use this section for additional documentation,
including, for example, documentation of refusals. If the beneficiary refuses to sign,
hospitals must record the refusal in this section and include the following components:
a. Name, title, and signature of the staff member who presented the notice.
b. A statement certifying that the notice was presented and a signature was refused.
The statement must include the name of the person who refused the notice. (See
example below.)
c. Date and time that the notice was presented and a signature was refused. This
information may be incorporated into the certifying statement as shown in the
example below.
Example of documentation when the beneficiary refuses to sign:
I, John Doe, Staff Nurse, certify that this notice was presented and explained to the
patient Jane Smith on 11/25/2015 at 11:00 p.m., and the patient refused to sign the
notice. John Doe, RN
QIO Name: Preprint or insert the name of the Quality Improvement Organization (QIO)
that performs reviews for the hospital.
QIO phone number: Preprint or insert the QIO’s phone number and TTY number.
Patient or Representative Signature: 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.