Senior Health and Retirement Services | Scope of Appointment Form

Scope of Appointment Confirmation Form

This form must be completed and signed prior to an appointment 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 who has Medicare or their authorized representative.

Click here to download, print and manually complete this form.

First Name

Last Name

Place a check mark in the box next to the type of products you want the agent to discuss.

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Advantage plans (Part C) and Medicare Cost plans

Medicare Health Maintenance Organization (HMO) plan, Medicare Preferred Provider Organization (PPO) plan, Medicare Private Fee-For-Service (PFFS) plan, Medicare Special Needs Plan (SNP), Medicare Medical Savings Account (MSA) plan, or Medicare Cost plan

Other health-related plans

Dental/vision/hearing products, supplemental health products, Medicare Supplement (Medigap) products

Signing this form does not obligate you to enroll in a plan, affect your current or future Medicare enrollment status, or automatically enroll you in the plans discussed.

Note: The person who will discuss the products is either employed or contracted by a Medicare plan. They don’t work directly for the federal government. This person may also be paid based on your enrollment.

Beneficiary or authorized representative signature and signature date:

Your Signature

Select a date

If you are signing as a power of attorney on behalf of someone else, please sign above and complete information below.

Representative Name:

Relationship to the beneficiary:

Thanks for submitting! We look forward to meeting with you!

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