Page 15 - Cover Letter and Medicare Evaluation for Jamie Marshall
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Client Data Sheet
Client ID: 202203k Rx Password Date: January 7, 2022
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 04/05/57
Date that Medicare became or will become primary (when client
has both Part A & Part B): 04/01/22
Client's home zip code: 12501
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
Continue to see following physicians:
Dr. Sandra Lithgow, Internist
Dr. Debra Pruzan, Dermatology
Dr. Carla Williams, Gynocology
Prescription Drugs
Current Refill Schedule: Monthly
Pharmacy: CVS
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