Scope of Sales Appointment Form
The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sales meeting to ensure 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 and should be completed by each person with Medicare or his/her authorized representative.

PLEASE CHECK BELOW THE TYPE OF PRODUCT(S) YOU WANT THE AGENT TO DISCUSS. AT LEAST ONE IS REQUIRED.
Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Advantage Plans (Part C) and Cost Plans
Dental/Vision/Hearing Products
Hospital Indemnity Products
Medicare Supplement (Medigap) Products
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed 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. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare Plan.

Beneficiary or Authorized Representative Signature and Signature Date
To be completed by Agent
 
 
 
 
 
 
 
 
 
[Plan Use Only]