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Please Fill out the Scope of Appointment.

The Scope of Appointment form is used to document an in-person or over the phone appointment with a beneficiary to ensure that no
other types of products are discussed outside of what the beneficiary
originally requested.

Scope of Appointment

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

Who is booking this appointment? *

Beneficiary

Authorized Representative

Agent

Your First Name

Your Last Name

Your Phone *

Your Email *

SOA Products (Product type descriptions are available at bottom of this page.) *

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Advantage Plans (Part C) and Cost Plans

Dental/Vision/Hearing Products

Hospital Indemnity Products

Medicare Supplement (Medigap) Products

Product type descriptions are available at bottom of this page

Please provide the Medicare beneficiaries' full name here *

What is your relationship to the beneficiary? *

Authorized Representative Signature *

Clear

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 or future enrollment, or enroll you in a Medicare plan.

Beneficiary Signature *

Clear

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 or future enrollment, or enroll you in a Medicare plan.

Non-Government Entity

NPN: 20734540 CA Lic# 6010030

Phone: 818-614-5973

Email: [email protected]

We do not offer every plan available in your area. Currently, we represent 8 organizations which offer 75 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options. This is a proprietary website and is not associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program please visit the Official U.S. Government Site for People with Medicare located at http://www.medicare.gov

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