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For more information about Medicare prescription drug
coverage:

 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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