Page 15 - Evaluation for Norm Ross
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Client Data Sheet
Client ID: 9362543616 Rx Password Date: October 19, 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: 10/16/47
Date that Medicare became or will become primary (when client 01/01/18
has both Part A & Part B):
Client's home zip code: 21702
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. Kusay Barakat Cardiologist Yes
Dr. Elizabeth Liotta Dermatologist Yes
Dr. Matt Yeatman Gastroenterologist Yes
Dr. Lee Krantz Internist Yes
Dr. David Levine Podiatrist Yes
Client wishes to evaluate Medigap coverage as well as Medicare Advantage plans
Prescription Drugs
Current refill schedule: Mail order
Pharmacy: Walgreens
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