Page 11 - Cover Letter and Medicare Evaluation for Diane Falten
P. 11
Client Data Sheet
Client ID: 630211030 Rx Password Date: November 1, 2021
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 07/22/53
Already enrolled in
Date that Medicare became or will become primary (when client
has both Part A & Part B): A&B for more than 6
months
Client's home zip code: 03820
Has client started receiving Social Security or SSDI payments? Yes
After client retires, will he or she have access to health insurance No
through a spouse's or ex-spouse's employer plan?
Client's Selection Criteria
Client wishes to enroll in Medicare Advantage plan
Prescription Drugs
Current refill schedule: Monthly
Pharmacy: CVS
5
