Page 15 - Cover Letter and Evaluation for Steve DIckhaus
P. 15
Client Data Sheet
Client ID: 1127571 Rx Password Date: November 25, 2019
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 03/23/55
Date that Medicare became or will become primary (when client
has both Part A & Part B): 03/01/20
Client's home zip code: 55127
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
Continue to see following physicians: this doctor accepts
assignment?
Dr. Robert C. Anderson Dermatologist Yes
Dr. Cynthia Frane Family Practice Yes
Prescription Drugs
Current refill schedule: monthly
Pharmacy: Walgreens
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