Scope of Appointment Confirmation Form

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.
Please check what you want to discuss with the Licensed Sales Representative.
Please check what you want to discuss with the Licensed Sales Representative.
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:
MM slash DD slash YYYY
If you are the authorized representative, please sign above and print clearly and legibly below:
Name(Required)
Address(Required)
Email(Required)
To be completed by Licensed Sales Representative (please print clearly and legibly)
Name
MM slash DD slash YYYY
Consent(Required)