Scope of Appointment Confirmation Form

The Centers for Medicare and Medicaid Services require agents to document the scope of a marketing appointment prior to any face-to-face sales meeting for ensuring 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.

By completing this form, you are agreeing to a meeting with a sales agent to discuss the types of products you specified 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.

Completing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.