Page 13 - Cover Letter and Medicare evaluation for Mr. Rod Fallow
P. 13
Client Data Sheet
Client ID: 630247 Rx Password Date: November 8, 2021
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 06/28/54
Date that Medicare became or will become primary (when client 08/01/21
has both Part A & Part B):
Client's home zip code: 94022
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?
Client's Selection Criteria
Does this provider
accept Medicare-
Continue to see following physicians:
approved rates
Dr. Nilufer Vesuna Family medicine Yes
Dr. Joe Field Dentist Not listed
Dr. Wendy Ni Ahn Doctor of Optometry Yes
Dr. Chris Renna General practice Not listed
Client would like to see comparisons of both types of coverage
Prescription Drugs
Current refill schedule: Monthly
Pharmacy: CVS
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