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Client Data Sheet
Client ID: 7892434304 Rx Password Date: March 4, 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: 05/14/52
Date that Medicare became or will become primary (when client
has both Part A & Part B): 04/01/17
Client's home zip code: 32783
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. Ralph Adams General Practice Yes
Dr. Samuel Bennett Cardiologist Yes
Dr. Lani Cunningham Dermatologist Does not indicate
Dr. Tom Duncan Chiropractor Does not indicate
Client wishes to evaluate Medigap coverage as well as Medicare Advantage plans
Prescription Drugs
Current refill schedule: Monthly (retail)
Pharmacy: CVS
5
