Medicare Outpatient Observation Notice Patient name: 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: A copayment for each outpatient hospital service you get. Part B copayments may vary by type of service. Observation services may affect coverage and payment of your care after you leave the hospital: 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 also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 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. "Self-administered 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. Please sign below to show you received and understand this notice. Signature of Patient or Representative Date / Time CMS does not discriminate in its programs and activities. To request this publication in alternative format, please call: 1-800-MEDICARE or email:AltFormatRequest@cms.hhs.gov.
20% of the Medicare-approved amount for most doctor services, after the Part B deductible.