Page 15 - Cover Letter and Evaluation for LuAnn Vander Vorste
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Client Data Sheet
Client ID: 4203328320 Rx Password Date: April 20, 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: 07/24/53
Date that Medicare became or will become primary (when client
has both Part A & Part B): 07/01/18
Client's home zip code: 95765
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. Rajeswari Chellappah Oncology Not indicated
Dr. Johanna Fuentes-Valdez Internal medicine Yes
Dr. Ann Haas Dermatology Yes
Dr. Melissa Johnson Ob-Gyn Yes
Dr. Kismet Roberts Family medicine Yes
Client is interested only in Medigap policies
Prescription Drugs
Refill Schedule: Monthly refills
Pharmacy: Bel-Air Pharmacy
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