Scope of Appointment Confirmation Form

The Centers for Medicare and Medicaid Services require agents to document the scope of a marketing appointment prior to any face-to-face sales meeting for ensuring understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential.

Products

Please check the product(s) below that you want the agent to discuss.

Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Advantage Plans (Part C) and Cost Plans
Medicare Supplement (Medigap) Products
Dental / Vision / Hearing Plans
Hospital Indemnity Plans

By completing this form, you are agreeing to a meeting with a sales agent to discuss the types of products you specified above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Completing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Are You The Person Seeking Coverage?

Authorized Representative

Your First Name

Your Last Name

Your Street Address

Your Street Address (line two)

Your City

Your State

Your Zip Code

Your Phone Number

Your Relationship to Beneficiary

Beneficiary

First Name

Last Name

Street Address

Street Address (line two)

City

State

Zip Code

Phone Number

Date of Meeting

Signature

I understand this is a legal representation of my signature.

By clicking "Submit", I have read and understand the contents of the Scope of Appointment form, and that I confirm that the information I have provided is accurate. If submitted by an authorized individual (as described above), this submission certifies that 1) this person is authorized under State law to complete the Scope of Appointment form, and 2) documentation of this authority is available upon request by Medicare.