Page 15 - Cover Letter and Evaluation for Forrest Hoover
P. 15
Client Data Sheet
Client ID: 85514x Rx Password Date: November 6, 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: 11/03/48
Date that Medicare became or will become primary (when 01/01/19
client has both Part A & Part B):
Client's home zip code: 46845
Has client started receiving Social Security or SSDI payments? No
After client retires, will he or she have access to health
insurance through a spouse's or ex-spouse's employer plan? No
Client's Selection Criteria Does the Medicare
web site indicate
that this doctor
Continue to see following physicians:
accepts Medicare-
approved rates?
Dr. Robert Godley Cardiology Yes
Dr. Gerald A. Kelty Family medicine Yes
Dr. Scott Palmer Urology Yes
Dr. Virendra Parikh Proctology Yes
Client would like to see comparisons of both types of coverage
Prescription Drugs
Refill schedule: Monthly
Pharmacy: CVS
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