Scope of Appointment

Medicare rules require us to document which types of plans you have agreed to discuss before we meet. It takes a minute, and it protects you: we may only talk about what you tick below.

This does not enroll you in any plan.
It does not change your current coverage.
You can change the scope at any time, including at the start of the meeting.
We keep a copy on file and can send it to you on request.

Your full name

Phone

Address

Which product types may we discuss?

We may only discuss the products you select here.

Medicare Advantage (Part C) and Medicare Advantage Prescription Drug plansStandalone Medicare Prescription Drug plans (Part D)Medicare Supplement (Medigap) productsDual-eligible Special Needs Plans (D-SNP)Hospital indemnity or other ancillary productsDental, vision, and hearing products

Agent name (if known)

I understand that this Scope of Appointment records the product types I agreed to discuss. Signing it does not obligate me to enroll in a plan, does not affect my current enrollment, and does not automatically enroll me in any plan. A sales agent may be paid based on my enrollment in a plan.

Type your name to sign

Typing your name here is your electronic signature.