Page 15 - Evaluation for Dirk Huybrechts
P. 15
Client Data Sheet
Client ID: 0226651648 Rx Password Date: September 12, 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: 01/25/49
Date that Medicare became or will become primary (when client
has both Part A & Part B): 10/01/17
Client's home zip code: 90049
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. Steven Ross Internal Medicine Need to verify
Dr. Michael Reynard Ophthalmologist Yes
Client wishes to evaluate Medigap coverage as well as Medicare Advantage plans
Prescription Drugs
Current refill schedule: Monthly
Pharmacy: CVS Pharmacy
5
