Page 15 - Cover Letter & Evaluation for David Steenburgen
P. 15
Client Data Sheet
Client ID: 9100980768 Rx Password Date: December 11, 2017
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 07/17/41
Date that Medicare became or will become primary (when client
has both Part A & Part B): 06/01/18
Client's home zip code: 85718
Has client started receiving Social Security or SSDI payments? Yes
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. James Sameshima Internal Medicine Yes
Client is interested only in Medigap policies
Prescription Drugs
Refill Schedule: Mail order
Pharmacy: Costco
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