Scope of Appointment

Scope of Appointment Confirmation

The Centers for Medicare and Medicaid Services (CMS) requires licensed sales agents to document the scope of the products that may be presented during a marketing appointment between the agent and the Medicare beneficiary (or their authorized representative) prior to a marketing meeting. All information provided on this form is confidential and should be completed by each person who has Medicare or their authorized representative. By signing this form, you agree to a meeting with a licensed sales agent to discuss the types of products you indicated below. The individual who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the federal government. This person may also be paid based on your enrollment. Signing this form does not obligate you to enroll in a plan, affect your current or future Medicare enrollment status, or automatically enroll you in plans discussed. You acknowledge the following products will be discussed based upon your state and county of residence: *Medicare Advantage plans (MAPD)Medicare Supplement plans (Medigap)Stand-alone Prescription Drug plans (PDP)Ancillary Products (Dental, Vision, Hearing, Accident, Critical Illness)Hospital Indemnity Products

To be completed by Beneficiary and/or Authorized Representative

Beneficiary First Name *

Beneficiary Last Name *

Beneficiary Address *

Beneficiary Phone Number *

Beneficiary Email

Authorized Representative

Your Relationship to Beneficiary

Signature of Beneficiary or Authorized Representative *The name entered is an electronic signature

Signature Date *I give consent to be contacted up to 12 months past the signature date.

To be completed by the Agent

Agent Name *

Agent Phone *

Initial Method of Contact *

Plan(s) the agent represented during the meeting

Agent Signature *The name and writing number entered is an electronic signature

Date of Agent Signature **Scope of Appointment documentation is subject to CMS record retention requirements

770-899-2429

Scope of Appointment Confirmation

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