24 SOA _ Pineda

Medicare Health Plans Scope of Appointment Form

Transitions Benefit Group 1.800.936.1405
Before meeting with a Medicare beneficiary (or their authorized representative) in person or remotely, Medicare requires that Licensed Sales Representatives obtain this form to ensure that only the plans and products Beneficiaries agree to are discussed in appointments. Please confirm if you agree to discuss these types of plans and products.
Plan Types You Wish to Discuss*

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Advantage Prescription Drug PlansMedicare Supplement (Medigap) PlansOther Health Insurance Products, Dental-Vision-Hearing, Hospital Indemnity
Date of Appointment with a representative of Transitions Benefit Group on or before: December 31, 2024. After submitting this form you can schedule an appointment on a date and time of your choosing.

By submitting this form, you agree to meet in person or remotely with a Licensed Sales Representative to discuss the products clicked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment. in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.
First Name *
Last Name*
Email
example@example.com
Signature*

Clear
Date*

MonthDayYear
Date
If you are authorized representative, sign above and print below:
Your relationship to the beneficiary:
Should be Empty:

Medicare Health Plans Scope of Appointment Form