Page 13 - Cover Letter and Evaluation for Bob Workman
P. 13
Client Data Sheet
Client ID: 7744939488 Rx Password Date: October 23, 2017
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 01/24/50
Date that Medicare became or will become primary (when client 01/01/15
has both Part A & Part B):
Client's home zip code: 99206
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
Continue to see following physicians: this doctor accepts
assignment?
Dr. Rosita Miranda General Medicine Yes
Client wishes to evaluate Medigap coverage as well as Medicare Advantage plans
Prescription Drugs
Current refill schedule: Mail order as well as retail
Pharmacy: Walgreens
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