Disclosure to CMS Form
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Entity/Plan Sponsor Information:
Entity Name:
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Entity Federal ID Number:
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Entity Street Address:
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City:
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State:
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Zip Code:
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Country:
United States
Phone Number:
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Coverage Type:
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Description of Other Type of Coverage:
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Creditable/Non-Creditable Offer:
Creditable/Non-Creditable Offer:
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Plan Year Beginning Date:
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Plan Year Ending Date:
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How many Options offered under this Plan are creditable?:
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Total Number of Medicare Part D Eligible Individuals expected to be covered under these creditable Benefit Option(s) as of the Plan Year Beginning Date stated above:
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Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan:
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How many Options offered under this Plan are not creditable?:
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Total Number of Medicare Part D Eligible Individuals expected to be covered under these Option(s) as Plan Year Beginning Date stated above:
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Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan:
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Date that the Annual Creditable Coverage Disclosure notice to Eligible Individuals form was provided by the Entity:
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Has your Creditable Coverage Status (Creditable, Non-Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year?:
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If yes, include the effective date(s) of this change:
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If yes, enter the date this Entity disclosed to Medicare Part D Eligible Individuals about this change in Creditable Coverage:
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I understand and agree to the following statements:
Entity's Authorized Individual Name:
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Entity's Authorized Individual Title:
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Entity's Authorized Individual Email:
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Today's Date:
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Page Last Modified:
06/19/2019 10:59 AM