Page 13 - Cover Letter and Evaluation for Susan Church
P. 13
Client Data Sheet
Client ID: 412603712 Rx Password Date: February 19, 2019
Please verify the accuracy of the information below and let us know if
changes need to be made.
Client's DOB: 03/21/54
03/01/19
Client's home zip code: 30327
Yes
No
Client's Selection Criteria
Does the Medicare
web site indicate
Continue to see following providers: that this doctor
accepts assignment?
Kriegel, William Primary Care Yes
Klopper, Jeffrey Psychiatrist Yes
Hannah, Karen Psycho-therapist Not listed
Harper, J. Sean Ophthalmologist Yes
Paladines, Jorge Dentist Not listed
Client is interested in Medicare Advantage plans
Prescription Drugs
Refill schedule: Monthly
Pharmacy: CVS
5
