Medicare SOA

Scope of Sales Appointment Confirmation Form

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Sales Agents use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary.

To be completed by the Beneficiary or Authorized Representative

Check the product type(s) you want the agent to discuss (required): (refer to the next page for product type descriptions) Medicare Advantage (Part C) Plans (HMO, PPO, HMO POS, MSA, PFFS, and/or SNP) Standalone Medicare Prescription Drug (Part D) Plans Medicare Supplement Other Medicare Health Plans (Cost Plans, PACE Plans)

Type a question

Medicare Advantage plans (Part C) and cost plansStandalone Medicare prescription drug (Part D) planMedicare Supplement (Medigap) productsDental-vision-hearing productsHospital indemnity products

Signature*

Signature Date

Date

If you are the Authorized Representative, please sign above and print below

Representative's name*

Relationship to Beneficiary

By signing this form, you agree to a meeting with a sales agent to discuss the product type(s) you checked above. The Sales Agent is either employer 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.

To be completed by the agent prior to meeting with beneficiary

Beneficiary name (required)

Beneficiary contact info (phone or address) (required)

Beneficiary Address

Email Address

example@example.com

Agent Name

Agent Phone Number

Agent NPN