Prepare for your Medicare benefits meeting. 📆

  • Let's get started!

    To find the right Medicare plan for you, I need a few details.

  • By submitting this form, you agree that a licensed insurance agent from CYA Insurance Agency may contact you by phone, text, or email to discuss your Medicare benefit options. You can unsubscribe at any time.

    CYA Insurance Agency is a licensed, independent insurance agency. We are not affiliated with the government or Medicare.

    🔒 Your information is secure and protected with AWS encryption. It will never be shared without your consent.

    Once your form is submitted, you'll be prompted to schedule a convenient appointment time with one of our agents.

  • Date of birth*
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  • Gender*
  • Format: (000) 000-0000.
  • How familiar are you with Medicare?*

  • Fun Fact

    Harry Truman was the first recipient of a Medicare card! ☝️
  • Tell me about your current health insurance*
  • Is your mailing address the same as your home address?*

  • Let's take a look at your current prescriptions.

    Enter your current prescriptions below. Spelling, dosage and frequency are important. - If not taking prescriptions, skip to next page.

  • What hospital(s) do you prefer?

  • Select all that apply.*

  • Tell us about your doctors and specialists.

  • Tell us about your preferences when it comes to your Medicare Plan.

    We will keep these in mind when providing plan options in your area.
  • Select which option best suits you:*

  • Do any of these apply to you?

  • Select all that apply:*

  • Let's wrap this up!

    The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any sales meeting to ensure 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.
  • CYA Insurance Agency

    Scope of Sales Appointment Confirmation Form

  • Select all the plans you would like your agent to discuss with you at the time of the appointment.

  • Stand-alone Medicare Prescription Drug Plans (Part D)

    Medicare Prescription Drug Plan (PDP) - A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

  • Would you like to discuss Part D drug plans?*

  • Medicare Advantage Plans (Part C) and Cost Plans

    Medicare Health Maintenance Organization (HMO)- A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).

    Medicare Preferred Provider Organization (PPO) Plan- A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

    Medicare Private Fee-For-Service (PFFS) Plan- A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan's payment, terms and conditions and agrees to treat you - not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers

    Medicare Special Needs Plan (SNP)- A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

    Medicare Medical Savings Account (MSA) Plan- MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

    Medicare Cost Plan- In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan's network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

  • Would you like to discuss Part C plans?*

  • Medicare Supplement Medigap Products

    Plans offering a supplemental policy to fill “gaps” in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.

  • Would you like to discuss Medigap plans?*

  • Hospital Indemnity Products

    Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare.

  • Would you like to discuss Hospital Indemnity benefits?*

  • Ancillary Products

    Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.

  • Would you like to discuss Ancillary benefits?*

  • The Federal government requires that all Medicare beneficiaries sign a Scope of Appointment form annually for each appointment related to reviewing or enrolling in Medicare benefits. This form must be retained in our records for at least 10 years and made available upon request.

  • After submission, you'll be prompted to schedule an appointment to discuss the quotes.

  • Format: (000) 000.0000.
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