Page 13 - Cover Letter and Evaluation for Clay Bassett

Client Data Sheet

Client ID: 4481933 Rx Password Date: May 15, 2018

Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.

Client's DOB: 11/18/44

Date that Medicare became or will become primary (when client
has both Part A & Part B): 07/01/18
Client's home zip code: 6880

Has client started receiving Social Security or SSDI payments? Yes

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. Russell Ciafone Cardiology Yes
Dr. Theresa Hadlock Otolaryngology Yes
Dr. John Papandrea Internal Medicine Yes
Dr. Jennifer Pennoyer Dermatology Yes
Dr. Joseph Petitti Optometry Yes
Dr. Felipe Santos Otolaryngology Yes

Client wishes to evaluate Medigap coverage as well as Medicare Advantage plans

Prescription Drugs
Current refill schedule: Mail-order
Pharmacy: CVS Pharmacy

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