LEGAL NOTICES
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:
Date: Name of Entity/Sender: Contact Position/Office: Address: Phone Number:
Callen Lorde
66
Callen Lorde BENEFITS GUIDE
LEGAL NOTICES I
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