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.

Medicare Advantage Plans (Part C) and Cost Plans

Stand-alone Medicare Prescription Drug Plan (Part D)

Medicare Supplement (Medigap) Plan

Dental-Vision-Hearing Products

Hospital Indemnity Products

View complete Medicare product descriptions.

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

Beneficiary’s First Name

Beneficiary’s Last Name

Beneficiary Address

Beneficiary's Phone

Authorized Representative First Name

Authorized Representative Last Name

Authorized Representative Address

Authorized Representative Phone

Relationship To The Beneficiary?

By checking this box, 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.

DATE SIGNED

Thank you, your scope of appointment has been submitted. Please close your browser.
Your broker will get in touch with you soon.

We'll Discuss your selected product(s).

Make sure you have the the following for our meeting:

Medicare Card
All medications
List of all your current physicians along with their phone numbers and addresses

Licensed Sales Representative Name

Licensed Sales Representative Phone

Licensed Sales Representative ID

Date Appointment Will Be Completed

Initial Method of Contact

Licensed Sales Representative Signature

SCOPE OF APPOINTMENT CONFIRMATION FORM

Thank you, your scope of appointment has been submitted. Please close your browser. Your broker will get in touch with you soon. We'll Discuss your selected product(s). Make sure you have the the following for our meeting:​

Medicare Card

All medications

List of all your current physicians along with their phone numbers and addresses

Thank you, your scope of appointment has been submitted. Please close your browser.
Your broker will get in touch with you soon.

We'll Discuss your selected product(s).

Make sure you have the the following for our meeting: