Page 13 - Evaluation for Jerri Zerlaut
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Client Data Sheet
Client ID: 2027377568 Rx Password Date: October 13, 2016
Please verify the accuracy of the information below and let us know if
To the Client:
changes need to be made.
Client's DOB: 12/31/52
Date that Medicare became or will become primary (when client
has both Part A & Part B): 01/01/18
Client's home zip code: 21054
Has client started receiving Social Security or SSDI payments? No
After client retires, will he or she have access to supplemental
health insurance from an employer plan? No
Client's Selection Criteria
Does the Medicare
web site indicate that
Continue to see following physicians: this doctor accepts
assignment?
Dr. Sammy Kang Dermatology Yes
Dr. Loc Le Gastroenterology Yes
Dr. Mark Okun Cardiology Yes
Dr. Neil Padgett Primary care Yes
Client is interested only in Medigap policies
Prescription Drugs
Refill Schedule: Mail-order
Client's pharmacy: CVS
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