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 Prescription Drug Plans (Part C) and Cost PlansMedicare Preferred Provider Organization (PPO) PlanMedicare Prescription Drug Plan (PDP)Dental / Vision
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated above. Please note, that 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.
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 beneficiary:
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty: