Page 7 - Cover letter and evaluation for Jerry Sicherman
P. 7
Client Data Sheet
Client ID: 5567179648 Rx Password Date: October 24, 2018
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 01/13/34
Date that Medicare became or will become primary (when client
09/01/00
has both Part A & Part B):
Client's home zip code: 90275
Has client started receiving Social Security or SSDI payments? Yes
After client retires, will he or she have access to health insurance
No
through a spouse's or ex-spouse's employer plan?
Client's Selection Criteria
Does the Medicare
web site indicate that
Continue to see following physicians: this doctor accepts
assignment?
Dr. David Cannom Cardiology Yes
Dr. John Gebhard Dermatology Yes
Dr. Wallace Goldban Ophthalmology Yes
Dr. Michael Hughes Family practice Yes
Dr. Angelica Malicdem General practice Not listed
Client is interested comparing current plans and in making sure he
has excellent catastrophic coverage
Prescription Drugs
Refill Schedule: Monthly
Pharmacy: Ralphs
1
