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Scope of Appointment

Important Notice:

This form documents what will be discussed in your meeting. Please select the product types you want to learn about and provide your information. Signing this form does NOT obligate you to enroll in any 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 compensated based on your enrollment in a plan.

Medicare Advantage & Cost Plans (Part C)

Medicare Preferred Provider Organization (PPO) Plan

Provides all Original Medicare Part A and Part B coverage including Part D prescription drug coverage. PPOs have network doctors but you can also use out-of-network providers at higher cost.

Medicare Health Maintenance Organization (HMO) Plan

Provides all Original Medicare Part A and Part B coverage including Part D prescription drug coverage. With most HMOs, you can only get care from in-network providers (except emergencies).

Stand-alone Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP)

A stand-alone drug plan that adds prescription drug coverage to Original Medicare.

Additional Products

Dental / Vision / Hearing

Medicare Supplement (Medigap) Products

Beneficiary Full Name

Beneficiary Phone Number

Email Address

Beneficiary Address

Select an Agent

Initial Method of Contact

Message

By checking this box, I consent to be contacted and agree to the Privacy Policy and Terms of Service.

Required by CMS for all Medicare sales meetings. By signing this form, you are not agreeing to change your plan. This form is used to grant permission to meet with a licensed agent.

*Please do not submit any Protected Health Information (PHI). You agree to be contacted by a Benefits Advisor or licensed sales agent to review your benefits.

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