Scope of Appointment Form

Scope of Appointment Form
The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment before any face-to-face sales meeting to ensure an 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 mark beside the type of product(s) you want the agent to discuss.*

Medicare Advantage PlansStand Alone Medicare Prescription Drug PlansDental/Vision/Hearing ProductsMedicare Supplement (Medigap) ProductsCritical Illness and Accident Products
By signing this form, you agree to meet with a licensed Health Plans in Oregon agent to discuss the types of products you indicated above. Please note that the agent is either employed by or contracted with a Medicare plan and does not work for the Federal government. Additionally, the agent may receive compensation based on your plan enrollment.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.
Health Plans in Oregon Agent:*
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address
example@example.com
If you are the authorized representative, please fill out the requested information below and sign.
Full Name:
Relationship to the beneficiary:
Signature*

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Date*

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Date
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