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) Drug-only plans that work alongside Original Medicare or a Medigap plan. Medicare Advantage Plans (Part C) and Cost Plans All-in-one plans (HMO, PPO, PFFS, SNP, MSA) that bundle hospital, medical, and usually drug coverage. Not connected to the federal government. Dental / Vision / Hearing Products Standalone dental, vision, or hearing coverage. These products are not affiliated with or connected to Medicare. Hospital Indemnity Products Pays a fixed cash benefit for covered hospital stays. Not affiliated with or connected to Medicare. Medicare Supplement (Medigap) Products Fills the gaps in Original Medicare (deductibles/coinsurance). Sold by private insurers; not connected to the federal government.

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 *

Date:

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.

Scope of Appointment

Why am I signing this?

Please read before signing

You're all set — thank you!