Scope of Sales Appointment Confirmation Form

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. (An authorized representative is someone who has legal POA for the beneficiary; This is typically a family member.) All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Please check the type of product(s) you want the agent to discuss.

(Refer below for product type descriptions)

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated 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.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary Signature and Signature Date:

If you are an authorized representative (aka: "POA") please print name below:

Today's Date:

Date & Time of Appointment:

General disclaimers

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week or your local State Health Insurance Program to get information on all of your options.

Agency represents Medicare HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. To learn more about a plan’s nondiscrimination policy, please click any of the Nondiscrimination links above in the Health plan disclaimers section.

This information is not a complete description of benefits. Call 1-877-258-9034 (TTY: 711) for more information.

Medicare beneficiaries may also enroll in the plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

Every year, Medicare evaluates plans based on a 5-star rating system.

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call the Plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Total annual cost is calculated by adding up the total annual cost of any monthly premiums, applicable plan deductible(s) and estimates for all co-pay and co-insurance amounts that will be due for the medications and health benefits used throughout the year. Costs for medications and health benefits vary across pharmacies and health systems, so the costs provided are only estimates. Actual costs could vary.

For plans with Part D Coverage: You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 8 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778 or consult www.socialsecurity.gov; or your Medicaid Office.

You must have both Part A and B to enroll in a Medicare Advantage plan. Members may enroll in the plan only during specific times of the year. Contact the plan for more information.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

To send a complaint to a Medicare Health Plan, call the Plan or the number on your member ID card. To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

Licensed insurance agent name: Brice Baxter, Initial method of contact: Email

Scope of Appointment documentation is subject to CMS record retention requirements.

Medicare Prescription Drug Plan (PDP) - A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost plans, some Medicare Private Fee-for-Service plans, and Medicare Medical Savings Account plans.

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO) - A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Preferred Provider Organization (PPO) Plan - 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.

Medicare Private Fee-For-Service (PFFS) Plan - A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Point of Service (POS) Plan - A type of Medicare Advantage Plan available in a local or regional area which combines the best feature of an HMO with an out-of-network benefit. Like the HMO, members are required to designate an in-network physician to be the primary health care provider. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Special Needs Plan (SNP) - A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan - MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan - In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan's network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Dental/Vision/Hearing Products

Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.

Hospital Indemnity Products

Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare.

Medicare Supplement (Medigap) Products

Plans offering a supplemental policy to fill “gaps” in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.