100763 An Important Message from Medicare about your Rights indd - virginia 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your Patient Name and MRN at the top of the form. This information is crucial for identifying your records.
  3. Fill in the Physician's name who is overseeing your care. This helps clarify who is responsible for your treatment.
  4. Review the rights outlined in the document carefully. Make sure you understand each right as a hospital inpatient, including your discharge rights.
  5. If you need to appeal a discharge decision, follow the steps provided on page 2. Ensure you contact KEPRO before your planned discharge date.
  6. Sign and date the form at the bottom to acknowledge that you have received this notice and understand your rights.

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Under federal law, hospitals must give you a MOON letter to inform you if youre being observed as an outpatient for more than 24 hours. Your status as inpatient versus outpatient affects how much you pay under Medicare during this time.
You have the right to be: Treated with courtesy, dignity and respect at all times. Protected from discrimination. Every company or agency that works with Medicare must obey the law.
You may get a Medicare Outpatient Observation Notice (MOON) that lets you know youre an outpatient in a hospital or critical access hospital. The hospital must give you this notice if youre getting outpatient observation services for more than 24 hours.
In a hospital: Within 2 days of your admission and prior to your discharge, you should get a notice called An Important Message from Medicare about Your Rights. This notice is sometimes called the Important Message from Medicare or the IM. If you dont get this notice, ask for it.
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