Page 15 - Cover Letter and Medicare Evaluation for Dorothy Schmitt
P. 15
Client Data Sheet
Client ID: 19970x4 Rx Password Date: November 3, 2022
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 12/31/52
Date that Medicare became or will become primary (when client Already in effect
has both Part A & Part B):
Client's home zip code: 19970
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 this provider
accept Medicare-
Continue to see following physicians:
approved rates
Jessica Hammond, NP Yes
Melissa Taylor, NP Yes
Prescription Drugs
Current Refill Schedule: Monthly
Pharmacy: Rite Aid
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