Page 13 - Cover letter and evaluation for Michele Buros
P. 13
Client Data Sheet
Client ID: 2133754848 Rx Password Date: February 23, 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: 04/19/52
Date that Medicare became or will become primary (when client
has both Part A & Part B): 03/01/18
Client's home zip code: 15146
Has client started receiving Social Security or SSDI payments? No
Yes No
Client's Selection Criteria
Does the Medicare
web site indicate that
Continue to see following physicians: this doctor accepts
assignment?
Dr. Francis Colangelo Internist
Yes
Dr. Sandra Rygg Gynecologist Yes
Client wishes to consider only Medicare Advantage plans (prefers PPO plans)
Prescription Drugs
Refill Schedule: Monthly (retail)
Pharmacy: Giant Eagle
5
