The Centers for Medicare & Medicaid Services requires agents to document the scope of a personal marketing appointment at least 48 hours prior to any individual sales meeting to ensure understanding of what will be discussed between the agent and 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 marked 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. If you would like to discuss additional products not marked above, a new form must be completed. This Scope of Appointment is only valid for 12 months after your signature date. 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 and Signature Date:

Signature: