Scope of Appointment Confirmation Form (SOA)

The Centers for Medicare and Medicaid Services requires agents to document this scope of a marketing appointment 48 hours prior to any individual meeting by phone, in person or otherwise 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. A new SOA is required if the beneficiary requests information regarding a different plan type than previously agreed upon. Place a check next to the type of product(s) you want the agent to discuss:

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Advantage Plans (Part C)

Medicare Supplement (Medigap) Products

Ancillary Products (Dental/Vision/Hearing Products)

Beneficiary or Authorized Representative Information:

By signing this form, you agree to a meeting with a representative 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. There is no obligation to enroll. Current or future Medicare enrollment status will not be impacted, and automatic enrollment will not

Your Authorized Signature and Date:

Your Signature:

Date:

Please enter your information here:

Agent Name:

Agent Phone:

Medicare Beneficiary Name:

Beneficiary Phone:

Your Address:

City:

State:

Zip Code:

Please Skip: This portion is for the agent.

Agent Signature:

Date Appointment Completed:

Agent / Caseworker Use:

Place all plan(s) you discussed with the beneficiary here do not leave blank.