Scope of Appointment for Medicare meeting

Scope of Appointment and Permission to Contact

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment 48 hours 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.
Medicare Advantage (Part C)Medicare Supplement (Medigap)Medicare Prescription (Part D)Ancillary Products
By signing this form, you agree to be contacted by a sales agent to discuss the types of products you indicated above. Contact methods may include phone calls, text messages or emails according to the information you provide. 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.
Please fill out the following details. Note: Each person enrolled in Medicare receives a Medicare Beneficiary Identifier number (MBI) on their Medicare card. Enter the information for the primary Medicare beneficiary (cardholder).
Beneficiary (in most cases, this is YOU)*

First NameMiddle NameLast Name
Street Address*
City*
State*
ZIP code*
Phone Number*
Please enter a valid phone number.
By clicking this box, I am providing my e-signature and express written consent agreement to permit Hebert Insurance Agency Inc, and parties acting on their behalf, to contact me at the above provided contact information for marketing purposes including through the use of automated technology, SMS/MMS messages subject to phone carrier fees and charges, AI generative voice, and prerecorded or artificial voice messages. I acknowledge that my consent is not required to obtain any goods or services, and to be connected without providing consent, I can call 406-755-6453.

Yes, opt-in
Email*
example@example.com
Are you an authorized representative acting on behalf of the beneficiary? (An authorized representative is a person chosen by the Medicare beneficiary to help with Medicare-related matters, such as the following: Researching and choosing Medicare coverage. Handling Medicare claims and payments. Appealing Medicare coverage decisions.)*
ONLY fill this out if you are the authorized representative for the beneficiary, such as a power of attorney etc.

First NameMiddle NameLast Name
By checking this box, 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.**

Agree.
Hebert Insurance Agency Inc, affiliated licensed insurance agents, PlanEnroll and iHaveMedicare.org are not associated, endorsed, or affiliated with the federal government, Social Security Administration, the Department of Health and Human Services or the Centers for Medicare and Medicaid Services (CMS). *We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE (24 hours a day/7 days a week) to get information on all of your options. *Please note, all calls are being recorded in compliance with CMS guidelines.
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Scope of Appointment and Permission to Contact