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Scope of Appointment 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 select the type of product(s) you want the agent to discuss. Click button to view product descriptions.
Please select an option based on your role:

Please type your name in the signature box below.  By doing so, you are agreeing to allow this to be used as your official electronic signature on this document only.

By signing using your electronic signature and submitting 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. Submitting this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Thanks for submitting this Scope of Appointment!

Agent Name:

Agent Phone:

Leslie L Watson

352-613-2187

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