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        Scope of Sales Appointment Confirmation Form

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. Please note that an agent may also discuss a Medicare Supplement policy with you.

Please initial below beside the type of product(s) you want the agent to discuss.

(Refer to page 2 for product type descriptions)

__Stand-alone Medicare Prescription Drug Plans 

__Medicare Advantage Plans (Part C) and Cost Plans


By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above
. 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.

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

Page 1 of 2

 

Beneficiary or Authorized Representative Signature and Signature Date:

Signature

Signature Date

If you are the authorized representative, please sign above and print clearly and legibly below:

Name (First_Last)


Relationship to Beneficiary


To be completed by Agent (please print clearly and legibly)

Agent Name (First_Last)

William Thompson

Agent Phone 


661-393-9050

Agent ID


204-8567

Beneficiary Name (First_Last)


Beneficiary Phone (Optional)

Date Appointment Completed

Beneficiary Address
 

(Optional)

Initial Method of Contact

Plan(s) the agent represented during the meeting

Agent’s Signature

Scope of appointment (SOA) is subject to CMS Record Retention Requirements

Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting: Please check all that apply

___Unplanned Attendee ____New SOA required (consumer requested other Health Product information)

Walk-in Other (please explain):________________________________________________________

Fax to: 1-866-994-9659

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