Page 15 - Cover Letter & Evaluation for Michael Novotny
P. 15
Client Data Sheet
Client ID: 14611187 Rx Password Date: June 11, 1018
Please verify the accuracy of the information below and let us know
To the Client:
if changes need to be made.
2640 1100 09/08/48
Date that Medicare became or will become primary (when
client has both Part A & Part B): 08/01/18
Client's home zip code: 92886
Has client started receiving Social Security or SSDI No
payments?
After client retires, will he or she have access to health
insurance through a spouse's or ex-spouse's employer No
plan?
Client's Selection Criteria
Does the Medicare
web site indicate
Continue to see following physicians: that this doctor
accepts assignment?
Michael Hall General practice Yes
Not covered
Client would like to see comparisons of both types of coverage
Prescription Drugs
Refill schedule: NA
Pharmacy: CVS
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