Scope of Appointment

Medicare Plans and Education Logo

Scope of Appointment Confirmation Form

The Centers for Medicare and Medicaid Services require agents to document the scope of a marketing appointment prior to any face-to-face sales meeting for ensuring 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.

Products

Please check the product(s) below that you want the agent to discuss.




By completing this form, you are agreeing to a meeting with a sales agent to discuss the types of products you specified 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.

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

Beneficiary

First Name
Last Name
Street Address
Street Address (line two)
City
State
Zip Code
Phone Number

Authorized Representative

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

Signature

I understand this is a legal representation of my signature.


By clicking "Submit", 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.