Scope of Sales Appointment Confirmation Form

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 individual 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 beside the type of product(s) you want the agent to discuss.
(Refer to page 2 for product type descriptions)

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Advantage Plans (Part C) and Cost PlansDental/Vision/Hearing ProductsSupplemental Health ProductsMedicare Supplement (Medigap) Products
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 or future enrollment, or enroll you in a Medicare plan.
Beneficiary or Authorized Representative Signature and Signature Date:
Signature

Clear
Signature Date

MonthDayYear
Date
If you are the authorized representative, please sign above and print below:
Representative’s Name
Your Relationship to the Beneficiary
To be completed by Agent:
Agent Name
Beneficiary Name
Agent Phone
Beneficiary Phone
Beneficiary Address
Initial Method of Contact: (Indicate here if beneficiary was a walk-in)
Agent’s Signature

Clear
Plan(s) the agent represented during this meeting
Date Appointment Completed

MonthDayYear
Date
Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting
Should be Empty:

Scope of Sales Appointment Confirmation Form

Beneficiary or Authorized Representative Signature and Signature Date: