Medicare Fact Finder & Scope of Appointment

THANK YOU for working with Trout Insurance. We appreciate your trust in us. Please take a few minutes to fill out the questions below. This form will help us verify your current coverage, as well as:
- Your Primary Care Physician, Specialists, Dentist and RX prescriptions.
- The Medicare benefits that you value the most.
- Any updates or changes you may have experienced.
Also, The CMS required Scope of Appointment form is included. This form grants us permission to work on your Medicare plan and shop around for the best options available.

We'll use this information to "Discover Your Options" for Medicare coverage.
What is your current plan type?

Please write the current company, premium, and length of time under your plan type. If you're covered under the VA/TriCare, an Employer, or State Retirement plan, please indicate that below.
Medicare Supplement
- Current Company? Current Company
- Current Premium? Current Premium
- How long have you been with this company? How Long
Stand-Alone Prescription Drug Plan
- Current Company? Current Company
- Current Premium? Current Premium
- How long have you been with this company? How Long
Medicare Advantage
- Current Company? Current Company
- Current Premium? Current Premium
- How long have you been with this company? How Long
Other Plan Types
Are you on Medicaid as well as Medicare?

YesNo
There are special Medicare Plans for those who have been diagnosed with Diabetes and/or Heart disease. Are you interested in learning about those plan options?

YesNo
Would you consider a plan that offers a "Giveback of Medicare Part B Premium" of up to $150 monthly ($1800 Annually)? This amount is applied to your Social Security monthly benefit.

YesNo
Who is your Primary Care Doctor?
(N/A if you do not have a Primary Doctor selected)
Please list any Specialist(s) you routinely see.
Who is your dentist?
Many Medicare Advantage Plans include dental

Please list any brand-name (expensive) prescription medications you're taking

	Medication Name	Dosage Amount	Frequency Taken	Reason Taken
Medication 1
Medication 2
Medication 3

Have you received your "Annual Notice of Change" (ANOC) for your current Medicare Advantage or Prescription Drug Plan?

YesNo

Rate the benefits on a scale of importance to you.

	Not Important	Somewhat	Very Important
If you're currently on a high-premium Medicare supplement – option to save money
Out of network coverage for specialists
Low Copay for inpatient hospital visits
Ability to see/keep my own doctor
Low Medical maximum out-of-pocket limit (Higher limits may have additional benefits)
Out-of-State coverage for medical care
Coverage for brand name medications
Dental benefit greater than $1,500 annually
Hearing aids
Medicare Part B Giveback (up to $1800 annually credited back to your social security)
Food card, Over the counter benefits
Gym membership (YMCA Covered)

Do you have any questions or concerns
Name*

First NameLast Name
Your Current Age*
What is your Part B effective date?
Located on the lower right of your Red, White, and Blue Medicare Card
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please click the "Next" button to continue

Scope of Appointment
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 an 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.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated 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.

Also, by signing this form; I acknowledge that David Trout has communictaed to me the following:

We may not offer every plan available in your area. Currently we represent at least 7 Medicare Advantage organizations which offer at least 50 different plan options in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP), to get information on all of your options.

As licensed insurance agents, we are required to follow the CMS rules as to how we work with consumers. These rules are there so you may require the information so you can make the best decision for your coverage. Under a new rule, we are required to have this completed 48 hours prior to an appointment. And, this SOA is valid for 12 months so we may collect this from you well in advance of our discussion. Thank You .

Agent Name(s): Dave Trout, David Hanson, Idelle Davids

Agent Phone Number: 828-658-1472
Name*

First NameLast Name
Signature*

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Date*

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Date
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What is your current plan type?

Medicare Supplement

Stand-Alone Prescription Drug Plan

Medicare Advantage

Please click the "Next" button to continue

Scope of Appointment