General Scope of Sales Appointment peoplesinsurancechoice October 10, 2023 Scope of Sales Appointment Confirmation Form The Centers for Medicare and 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. Please initial below beside the type of product(s) you want the agent to discuss Discussed 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 (Medicare Recipient) Beneficiary Name (Medicare Recipient) Beneficiary Phone Beneficiary Address By signing this 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 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 enrollment, or enroll you in a Medicare Plan. Beneficiary or Authorized Representative Signature Clear Signature Date -Month -DayYearDate If you are the authorized representative, please sign above and print below Representative's Name Your Relationship to the Beneficiary Agent Name Agent Phone Initial Method of Contact: (Indicate her if beneficiary was a walk in.) Agent fills this in please. Agent's Signature Clear Plan(s) the agent represented during this meeting Date Appointment Completed /Month /DayYear Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting *Scope of Appointment documentation is subject to CMS record retention requirements* Submit Should be Empty:
