Page 9 - Evaluation for Tom Tappan
P. 9
Client Data Sheet
Client ID: 2783804512 Rx Password Date: October 9, 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: 07/04/65
Date that Medicare became or will become primary (when client 11/01/10
has both Part A & Part B):
Client's home zip code: 60613
Has client started receiving Social Security or SSDI payments? Yes
After client retires, will he or she have access to health insurance
through his or her employer plan or through a spouse's or ex- Yes
spouse's employer plan?
Client's Selection Criteria
Does the Medicare
web site indicate that
Continue to see following physicians: this doctor accepts
assignment?
Dr. Robert Todd Hargan Internal medicine Yes
Client wishes to compare employer plan options to Medigap policies
Prescription Drugs
Current refill schedule: Monthly
Pharmacy: Walgreens
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