Page 32 - Benefits Enrollments Guide - Hospice of WS

 Visit www.medicare.gov
 Call you State Health Insurance Assistance Program (see
the inside back cover of you copy of the “Medicare & You”
handbook for their telephone number) for personalized help Call 1-
800-MEDICARE or (1-800-633-4227). TTY users 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 users call 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: April 20, 2017

Name of Entity/Sender: Hospice & Palliative CareCenter
Contact- Position/Office: Shelly Beard

Address: 101 Hospice Lane Winston-Salem, NC 27103

Phone Number: 336.331.1216

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 C4-26-05, Baltimore, Maryland 21244-1850.

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