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 Plans
Medicare Preferred Provider Organization (PPO) Plan
Medicare Prescription Drug Plan (PDP)
Dental / Vision
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Date of Appointment
-
Month
-
Day
Year
Date
If you are the authorized representative, please fill out the requested information below and sign.
Name
First Name
Last Name
Signature
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Should be Empty: