Page 15 - Evaluation for 2018
P. 15
Client Data Sheet
Client ID: 1321108544 Rx Password Date: January 3, 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: 07/16/50
Date that Medicare became or will become primary (when client
has both Part A & Part B): 03/01/18
Client's home zip code: 99005
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. Smith Yes
Dr. Jones Yes
Dr. Miller Yes
Client would like to see comparisons of both types of coverage
Client may decide to delay retirement depending on health care
costs
Prescription Drugs
Current refill schedule: Mail order
Pharmacy: CVS
5
