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The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of an appointment prior to any face-to-face 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.

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Please choose the type of product(s) you want the agent to discuss(Required)

Stand-alone Medicare Prescription Drug Plans (Part D) – A stand-alone drug plan that adds prescription drug coverage to Original Medicare certain Medicare plans.

Medicare Advantage Plans (Part C/MA) – A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

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