Scope of Appointment Confirmation Form: Jim Poling

Scope of Appointment Confirmation Form
Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives 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. Please check what you want to discuss with the Licensed Sales Representative.

Medicare Advantage Plans (Part C) and Cost PlansDental-Vision-Hearing ProductsStand-alone Medicare Prescription Drug Plan (Part D)Hospital Indemnity ProductsMedicare Supplement (Medigap) Plan
By signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked 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.
Beneficiary or Authorized Representative Signature and Signature Date:
Signature (Type out full name)
Today’s Date

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Date
Should be Empty:

Scope of Appointment Confirmation Form