Page 15 - Cover Letter & Evaluation for Carol Evans
P. 15
Client Data Sheet
Client ID: 44971 Rx Password Date: June 8, 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: 08/23/53
Date that Medicare became or will become primary (when client
has both Part A & Part B): 08/01/18
Client's home zip code: 85718
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. Dawn Lemcke Internal Medicine Yes
Dr. Jeff Maltzman Ophthalmology Yes
Client is interested only in Medigap policies
Prescription Drugs
Refill Schedule: NA
Pharmacy: Walgreens
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