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Scope of Sales Appointment Confirmation

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face or telephonic appointment 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 the product(s) below that you want the agent to discuss

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated 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 obligated you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. 

Thanks for submitting!

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