Scope of Sales Appointment Confirmation Form

Please initial below beside the type of product(s) you want the agent to discuss. (Refer to page 2 for product type descriptions)

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 Beneficiary or Authorized Representative Signature:

*Scope of Appointment documentation is subject to CMS record retention requirements * A Coordinated Care plan with a Medicare Advantage contract and a Medicare-approved Part D sponsor