LEGAL NOTICES
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 (apenalty).
Medicare Eligible Individual’s Name Individual’s DOB or unique Member ID:
The individual stated above has been covered under creditable prescription drug coverage for the following date ranges that occurred after May 15, 2006: From:
To:
Contact--Position/Office:
Address:
Phone Number:
63
Callen Lorde BENEFITS GUIDE
LEGAL NOTICES I
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