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Medicare Scope of Appointment

Scope of Appointment Confirmation Form

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires
that Sales Agents use this form to ensure your appointment focuses only on the type of plan and
products you are interested in. A separate form should be used for each Medicare beneficiary.
Please check what you want to discuss with the Sales Agent (See the back of this page for
definitions):

By signing this form, you agree to meet with a Sales Agent to discuss the products checked above.
The Sales Agent is either employed or contracted by a Medicare plan and may be paid based on
your enrollment in a plan. They do not work directly for the federal government.
Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in
a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is
confidential.

Beneficiary or authorized representative signature and signature date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 28, 2024 2:53pm GMT

Medicare Scope of Appointment Uploaded by Thomas Qualley - tom@sovselect.com IP 70.92.228.87