SCOPE OF APPOINTMENT FORM

AS REQUIRED UNDER 42 CFR § 422.2264(c)(3)

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face 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.

Select ALL of the products below that you would like the agent to discuss

Medicare Prescription Drug Plans (Part D)Medicare Advantage Plans (Part C)Medicare Supplement (Medigap) ProductsAncillary Products (Dental, Vision, Hearing)

Click here to read a description of each product.

Beneficiary Information

Name

*Address (Line 1)Address (Line 2)*City*State*Zip Code*Phone Number*Email

Your signature

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. All information provided on this form is confidential.

Date Signed

- Sign Here

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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.

Your information will be provided to a licensed insurance agent. You may be contacted by a licensed insurance agent.