"*" indicates required fields

Please initial below beside the type of product(s) you want the agent to discuss.

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative).

Medicare Advantage Plans (Part C) and Cost Plans

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Medicare Special Needs Plan (SNP)

A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

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Medicare Health Maintenance Organization (HMO)

A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

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Optional Supplemental Dental Plans

Administered by Delta Dental Insurance Company

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Signature

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Signature Date

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Hidden Fields Above

Agent Name:*

Agent Email:*

Agent Phone:*

Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face 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.
Fields marked with an asterisk (*) are required.

Please check one or ALL 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

Ancillary Products

Beneficiary or Authorized Representative Information

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above.
Agreeing to this appointment does not affect your current or future Medicare enrollment status and there is no obligation to enroll. In addition, completing this confirmation will not automatically enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan. Beneficiary or Authorized Representative Signature and Signature Date:

If you are the authorized representative, please sign above and print below:

Beneficiary Name:*

Beneficiary Address:*

Beneficiary Phone:

Are you the authorized representative acting on behalf of the beneficiary?

Yes

Authorized Representative’s Name:*

Representative Address:*

Beneficiary Phone:*

Your Relationship to the Beneficiary:*

Checked

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.