Page 15 - Evaluation with Cover Letter for Henry Rose
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Client Data Sheet
Client ID: 9912552448 Rx Password Date: September 16, 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: 08/09/49
Date that Medicare became or will become primary (when client
has both Part A & Part B): 10/01/17
Client's home zip code: 22202
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. Christopher Walsh Family practice Yes
Dr. Fred Steir Urology Need to verify
Dr. Glenn Fuchs Dermatology Yes
Client wishes to evaluate Medigap coverage as well as Medicare Advantage plans
Prescription Drugs
Refill Schedule: Mail order
Pharmacy: Costco
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