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CREDITABLE COVERAGE DISCLOSURE TO INSTRUCTIONS & …

CENTERS FOR medicare & MEDICAID SERVICES CREDITABLE COVERAGE DISCLOSURE TO CMS INSTRUCTIONS & SCREEN SHOTS Form Approved OMB No. 0938-1013 5/29/2012 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 0938-1013. The time required to complete this information collection is estimated to average 5 minutes per response, 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.

coverage to any other Medicare Part D eligible individual (active, disabled, COBRA or any retirees or dependents who are covered by the employer or union but are not being claimed under the RDS), they must provide a Disclosure to CMS Form for those plan options that cover those

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  Medicare, Coverage, Disclosures, Cobra, Creditable, Creditable coverage disclosure

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