"*" indicates required fields

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Page URL

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Flowtype

Workflow

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Agent SOA CMS Link

Scope ID

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Agent Email:*

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 check beside the type of product(s) you want to discuss

(Refer to page 2 for product type descriptions)

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Advantage Plans (Part C) and Cost Plans

Dental / Vision / Hearing Products

Hospital Indemmity Products

Medicare Supplement (Medigap) Products

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 and Signature Date

Beneficiary Name:*

Beneficiary Email:*

Beneficiary Phone:

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Phone

Beneficiary Address (optional)

Beneficiary or Authorized Representative Signature*

Sign Here

Signature Date*

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

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Representative’s Name:

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Your Relationship to the Beneficiary:

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To be completed by Agent

Agent Name:*

(View only)

Agent Phone:*

(View only)

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Initial Method of Contact:

(Indicate here if beneficiary was a walk-in.)

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Agent's Signature:

(Indicate here if beneficiary was a walk-in.)

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Plan(s) the agent represented during this meeting:

(Indicate here if beneficiary was a walk-in.)

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Date Appointment Completed:

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(Plan Use Only)

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If the form was signed by the beneficiary at time of appointment, provide explanation why Sales Appointment Confirmation was not documented prior to meeting: