Page 13 - Cover Letter and Evaluation for Dr. Herman Kensky
P. 13
Client Data Sheet
Client ID: 3588125 Rx Password Date: November 13, 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: 08/12/49
Date that Medicare became or will become primary (when client
has both Part A & Part B): 01/01/18
Client's home zip code: 31411
Has client started receiving Social Security or SSDI payments? NA
After client retires, will he or she have access to health insurance
through a spouse's or ex-spouse's employer plan? NA
Client's Selection Criteria
Does the Medicare
web site indicate that
Continue to see following physicians: this doctor accepts
assignment?
Client has not yet selected physicians in area he's moving to
Client wishes to evaluate Medigap policies
Prescription Drugs
Refill Schedule: NA -- Client does not take any Rx drugs
Pharmacy: NA
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