Page 13 - Cover Letter and Evaluation for Bob O'Connell
P. 13
Client Data Sheet
Client ID: 4815678688 Rx Password Date: October 5, 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: 08/29/53
Date that Medicare became or will become primary (when client
has both Part A & Part B): 11/01/18
Client's home zip code: 28226
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. Carlos Jorge Primary Care Yes
Dr. Robert Kipnis Rheumatology Yes
Dr. Anita Wu Neurology Yes
Dr. Michael Brennan Oral Medicine Yes
Dr. Vandanna Minnal Eye Specialist Yes
Client is interested only in Medigap policies
Prescription Drugs
Refill Schedule: Monthly
Pharmacy:
5
