The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any 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.

• Stand-alone Medicare Prescription Drug Plans (Part D)

• Medicare Advantage Plans (Part C) and Cost Plans

• Dental/Vision/Hearing Products

• Hospital Indemnity Products

• Medicare Supplement (Medigap) Products.

By signing this form, you agree to a meeting with a sales agent to discuss all the products indicated above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They work directly for the federal government. This individual may also be paid based on your enrollment in a plan.

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