Scope of Appointment Confirmation Form

Before meeting with a Medicare beneficiary (or their authorized representative), Centers for Medicare and Medicaid Services requires that licensed sales representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary. Please select each product you wish to discuss with a licensed sales representative.

By signing this form, you agree to meet with a licensed sales representative to discuss the products initialed above. The licensed sales representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government.

Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.