Page 15 - Cover letter and evaluation for Jack Hosier
P. 15
Client Data Sheet
Client ID: 9008683968 Rx Password Date: November 14, 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: 09/26/45
Date that Medicare became or will become primary (when client 01/01/18
has both Part A & Part B):
Client's home zip code: 90803
Has client started receiving Social Security or SSDI payments? Yes
After client retires, will he or she have access to health insurance No
through a spouse's or ex-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. Joe Chen Yes
Dr. SIdney Newman Yes
Dr. Abelardo Pita Yes
Client wishes to evaluate Medigap policies only
Prescription Drugs
Refill Schedule: Mail-order
Pharmacy: CVS
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