Scope of Appointment Confirmation Form

Scope of Appointment Confirmation Form

Please provide us with some information about the Medicare beneficiary to be discussed on the call with the Licensed Sales Representative.
Name
N/A

Required First Name Required Last Name
Phone *
N/A
Email Address *
N/A
Mailing Address
N/A

Required
Street Address Required City Required State/Region/Province Required
Postal / Zip Code
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. Please indicate the product(s) you agree to discuss by checking the applicable checkbox(es)
N/A

Medicare Advantage Plans (Part C) and Cost Plans [✔] [ ] Medicare Advantage Plans (Part C) and Cost Plans
N/A

Dental-Vision-Hearing Products [✔] [ ] Dental-Vision-Hearing Products
N/A

Stand-alone Medicare Prescription Drug Plan (Part D) [✔] [ ] Stand-alone Medicare Prescription Drug Plan (Part D)
N/A

Hospital Indemnity Products [✔] [ ] Hospital Indemnity Products
N/A

Medicare Supplement (Medigap) Plan [✔] [ ] Medicare Supplement (Medigap) Plan
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 Signature and Date:
Are you acting as Power of Attorney (POA) for the person listed?
N/A

Yes
No
Person Named as Power of Attorney
N/A
Relationship to person
N/A
Signature *
N/A

E-Signature Field
Clear
Date of Signature *
N/A

MM/dd/yyyy
Would you like to schedule your appointment now? *
N/A

Yes
No
CRM Owner ID
N/A
Agent Name
N/A
Agent Phone
N/A
Form Name For CRM
N/A
SOA Agent ZBooking ID
N/A

Scope of Appointment Confirmation Form

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