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OMB 0938-0990
Call your State Health Insurance Assistance Program (see the inside back cover of your copy
of the “Medicare & You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage
is available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of
the Medicare drug plans, you may be required to provide a copy of this notice
when you join to show whether or not you have maintained creditable coverage
and, therefore, whether or not you are required to pay a higher premium (a
penalty).
Date: October 2022
Name of Entity/Sender: Mona Lalla
Contact--Position/Office: Human Resources
Address: 3750 Investment Lane. Suite 2
Palm Beach Gardens, FL 33404
Phone Number: 561-707-6032
CMS Form 10182-NC Updated April 1, 2011
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 0938-0990. The time required to complete this information collection is estimated to average 8 hours
per response initially, 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 C32-26-05, Baltimore, Maryland 21244-1850.
