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














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