Scope of Sales Appointment Confirmation Form

The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face or telephone sales meeting to ensure understanding of what will be discussed between the agent and the Medicare member (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his or her authorized representative.

Please check the options below beside the type of products you want the agent to discuss. (Refer to the following page for product type descriptions.) *

Stand-alone Medicare prescription drug plans (Part D)

Medicare Advantage plans (Part C)

Dental/vision/hearing products

Ancillary products (not Medicare-affiliated)

Medicare supplement (Medigap) products

By signing the 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 don’t 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 status, or automatically enroll you in a Medicare plan.

Member or authorized representative signature and signature date. *

Member Email: *

Member Phone: *

Today's Date:

Client Signature: *

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

Fields below to be completed by agent.

Agent Name:

Agent Phone:

Member First Name:

Member Last Name:

Your relationship to the member:

Member Address:

Initial method of contact (indicate here if member was a walk-in).

Agent's Signature

Clear

Agent's Signature

Plans represented by agent during meeting

Date appointment completed

Are you a walk-in or did you call in day of appointment? (Yes or No)

Yes

Scope of Appointment documentation is subject to CMS record retention requirements.

Stand-alone Medicare prescription drug plans (Part D)

Medicare Prescription Drug Plan (PDP) – A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare cost plans, some Medicare private fee-for-service plans and Medicare medical savings account plans.

Medicare Advantage plans (Part C)

Medicare health maintenance organization (HMO) – A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare preferred provider organization (PPO) plan – A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare private fee-for service (PFFS) plan – A Medicare Advantage plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all providers will. If you join a PFFS plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see

out-of-network providers.

Medicare special needs plan (SNP) – A Medicare Advantage plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who live in nursing homes, and people who have certain chronic medical conditions.

Dental/vision/hearing products

Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.

Ancillary products

Critical illness and accident insurance – Plans offering coverage for consumers who have been diagnosed with a specific illness on a predetermined list. These plans are not affiliated or connected to Medicare.

Hospital indemnity insurance – Plans that offer coverage each day you are hospitalized, up to a designated number of days. These plans are not affiliated with or connected to Medicare.

Travel insurance – Plans offering additional benefits for consumers who travel outside the United States. These plans are not affiliated or connected to Medicare.

Medicare supplement (Medigap) products

Plans offering a supplemental policy to fill “gaps” in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.