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Scope of Appointment
Scope of Appointment
Scope of Appointment Confirmation Form
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Scope of Appointment Confirmation Form
Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary. Please check what you want to discuss with the Licensed Sales Representative:
What would you like to discuss?
Medicare Advantage Plans (Part C) and Cost Plans
Stand-alone Medicare Prescription Drug (Part D) Plan
Medicare Supplement (Medigap Products)
Dental-Vision-Hearing Products
Hospital Indemnity Products
By signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do NOT work directly for the federal government. Signing this form does NOT affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan, or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.
Beneficiary or Authorized Representative Signature and Signature Date
Electronic Signature Field
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Today's Date
*
If you are the authorized representative, please sign above and enter your name below.
Name
Relationship To Beneficiary
Email
This field is for validation purposes and should be left unchanged.
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