Page 7 - Cover Letter & Evaluation for Jane Stewart
P. 7
Client Data Sheet
Client ID: 9837747776 Rx Password Date: October 25, 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: 02/15/39
Date that Medicare became or will become primary (when client
has both Part A & Part B): 02/01/04
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
through a spouse's or ex-spouse's employer plan? No
Client's Selection Criteria Does the Medicare
web site indicate that
this doctor accepts
Continue to see following physicians:
Medicare-approved
rates?
Dr. Mary Doost Internal medicine Yes
Dr. Sean Fischer Hematology Yes
Dr. Ramin Modabber Orthopedic surgery Yes
Dr. Vinita Verghese Internal medicine Yes
Dr. Forrest Wright Cardiology Yes
Client wants to evaluate her current coverage
Prescription Drugs
Refill Schedule: Monthly
Pharmacy: Ralphs
1
