The Centers for Medicare & 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.

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

Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans

Medicare Advantage Plans (Part C) and Cost Plan

• Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Planthat provides all Original Medicare Part A and Part B health coverage and sometimescovers Part D prescription drug coverage. In most HMOs, you can only get your carefrom doctors or hospitals in the plan’s network (except in emergencies).
• Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan thatprovides all Original Medicare Part A and Part B health coverage and sometimescovers Part D prescription drug coverage. PPOs have network doctors and hospitalsbut you can also use out-of-network providers, usually at a higher cost.
• Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in whichyou may go to any Medicare approved doctor, hospital and provider that accepts the plan’spayment, terms and conditions and agrees to treat you – not all providers will. If you join aPFFS Plan that has a network, you can see any of the network providers who have agreed toalways treat plan members. You will usually pay more to see out-of-network providers.
• Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefitpackage designed for people with special health care needs. Examples of the specific groupsserved include people who have both Medicare and Medicaid, people who residein nursing homes, and people who have certain chronic medical conditions.
• Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a highdeductible health plan with a bank account. The plan deposits money from Medicare into theaccount. You can use it to pay your medical expenses until your deductible is met.
• Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in andout of network. If you get services outside of the plan’s network, your Medicare-coveredservices will be paid for under Original Medicare but you will be responsible for Medicarecoinsurance and deductibles.

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 or Authorized Representative Signature and Signature Date:

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

To be completed by Agent:

Scope of Appointment documentation is subject to CMS record retention requirements.

Health coverage is offered by Blue Cross and Blue Shield of Florida, DBA Florida Blue. HMO coverage is offered by Florida Blue Medicare Inc., which is an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent licensees of the Blue Cross and Blue Shield Association.