• Medicare Scope of Appointment & Permission to Contact

    Please complete and sign this form before your scheduled appointment. Keep a copy of this form for your records.

  • Expiration Date: 01/06/2035

    Scope of Appointment Confirmation Form
    CMS Consent Form for Health Insurance Medicare Agents and Brokers
    I give my permission to SHACKISHA CLARK to serve as the health insurance agent or broker for myself for purposes of enrollment in a Qualified Medicare Plan By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

    • Agreement to meet with the licensed insurance agent to discuss Medicare products. Federal law requires that a completed Scope of Appointment form be obtained prior to discussing Medicare Advantage (MA) Plans, Prescription Drug Plans (PDPs), or Medicare Supplement Insurance Policies.

    I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting CMS.gov

    AGENT ACKNOWLEDGMENT: 

    I certify that I have explained the purpose of this form to the beneficiary, and I have not discussed any products or plans not approved by the beneficiary prior to obtaining this signed Scope of Appointment form.

    Name of Primary Writing Agent: SHACKISHA CLARK

    • National Producer Number: 19092685
    • GA Resident Agent License Number is 3196512
    • Phone Number: 678-994-4069
    • Email Address: insurance@lifetimetaxprofessionals.com
  • Beneficiary Date of Birth*
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  • Format: (000) 000-0000.

  • Scope of Appointment Details

    I, the undersigned Medicare beneficiary, authorize the licensed agent listed above to contact me and meet with me to discuss the following Medicare products I understand that the agent listed above may only discuss the products that I have selected. If I wish to discuss additional products, a new Scope of Appointment form will be required. Completing this form does not obligate me to enroll in a plan, and I may end the appointment at any time. (Check all that apply):
  • Type of Plans*

  • Acknowledgement Disclaimer

    I understand that the agent listed above may only discuss the products that I have selected in Section 3. If I wish to discuss additional products, a new Scope of Appointment form will be required. Completing this form does not obligate me to enroll in a plan, and I may end the appointment at any time.
  • Appointment Date & Time
     - -

  • Permission to Contact Medicare Authorization Form

  • Name of Authorized Representative: Shackisha Clark

    Phone Number: 678-994-4069

    Address: Virtual Services Metro-Atlanta, Georgia

    Relationship to Beneficiary: Broker of Record

    Purpose of Authorization I, the undersigned Medicare beneficiary, authorize the above-named individual or organization to contact Medicare on my behalf and to access the following information:

    • Enroll in Medicare Plans
    • This authorization will assist me with my Medicare-related inquiries, claims, or appeals. 

    This authorization will expire on: 1/6/2035.

    I understand that I may revoke this authorization at any time by submitting a written request to the organization or individual named above. Revoking this authorization will not affect any action taken based on this authorization before the revocation was received.

    SIGNATURE:

    I understand that my health information is private, and by signing this form, I am allowing the release of my Medicare information to the individual or organization listed above. I understand that this authorization is voluntary and that I may refuse to sign this form. A copy of this form shall be as valid as the original.

  • Today's Date*
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  • Should be Empty: