Wayne G Fraser

Licensed Medicare Specialist

✅ License Verified

CMS Required Form

Medicare Scope of Appointment

Federal Medicare regulations require this form before discussing Medicare Advantage, Prescription Drug Plans, or Medicare Supplement products.

IMPORTANT: Signing this form does NOT enroll you in a Medicare plan. Signing this form does NOT require you to purchase coverage. This form only authorizes discussion of the Medicare products you select below.

What Would You Like To Discuss?

Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) Medicare Supplement Plans (Medigap) Dental / Vision / Hearing Products

Beneficiary Information

Full Name

Phone Number

Address

City

State

ZIP Code

Your Signature

Date

Your electronic signature confirms that you authorize discussion of the selected Medicare products.

I understand that signing this Scope of Appointment does not obligate me to enroll in any Medicare plan and only authorizes discussion of the products selected above.

🔒 Agent Use Only

After submission, the licensed Medicare professional will complete the required compliance documentation and certification. No action is required from you.