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 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. 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 enrollment or enroll you in a Medicare Plan.

Beneficiary First Name *

Beneficiary Last Name *

Beneficiary Street Address *

Beneficiary City *

Beneficiary State *

Beneficiary Postal code *

Email *

Phone *

Are you the authorized representative *

Beneficiary or Authorized Representative Signature *

Clear

Date signed *

Scope of Sales Appointment Form (To Be Completed by Agent)

Scope of Appointment form needs to be completed and submitted for all scheduled appointments (even for no-shows, cancelled appointments, or those that do not result in a sale)

Agent Name:

Agent Phone:

Initial Method of Contact:

If the SOA form wasn't completed 48 hours in advance, please provide details below:

Plans Represented during this meeting:

Date Appointment Completed:

I confirm the information represented here is true and accurate. I authorize my signature on the Scope of Appointment form using this information.