Medicare compliance · No obligation

Scope of Appointment

Before a licensed agent can talk through specific Medicare options with you, Medicare asks us to record which topics you’d like to cover. It takes about two minutes — and it doesn’t sign you up for anything.

Why am I signing this?

This form is not an application. It does not enroll you in any plan, change your current Medicare, or obligate you to buy anything. The government (CMS) simply requires agents to note ahead of time which kinds of coverage you want to discuss, so the conversation stays focused on what you asked about. You’re in control — pick only the topics you’re curious about.

1. Which topics would you like to discuss?

Choose all that apply. You can change this anytime — nothing here is binding.

Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) and Cost Plans Dental / Vision / Hearing Products Hospital Indemnity Products Medicare Supplement (Medigap) Products

2. Your information

Full name *

Phone

Email (so we can send you a copy)

Street address

City

State

ZIP

3. Who is completing this form?

I am the person with Medicare I am an authorized representative

4. Appointment details

Agent you're meeting

How did you first get in touch?

Please read before signing

The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual 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.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you selected 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 or future Medicare enrollment, or automatically enroll you in the plan(s) discussed.

5. Sign electronically

Type your full legal name as your signature *

I agree to use an electronic signature and to receive this form and my copy electronically (ESIGN/UETA).

I have read the statement above and the typed name is my signature.

This Scope of Appointment is retained for 10 years as required by CMS (42 CFR §§422.2264, 423.2264) and is valid for 12 months from the date you sign. It is used only to document the topics you agreed to discuss.

Important: We do not offer every plan available in your area. Currently we represent several organizations offering Medicare Advantage, Medicare Supplement (Medigap), and Part D plans in your state. Please contact Medicare.gov, call 1-800-MEDICARE, or contact your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.

Not connected with or endorsed by the United States government or the federal Medicare program.