Acquire Healthcare

Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment before any face-to-face sales meeting to ensure an 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.

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

Medicare Advantage Prescription Drug Plans (Part C) and Cost Plans


A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and includes 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.


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

Stand-alone Medicare Prescription Drug Plans (Part D)


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.

Additional Products

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated above. Please note, that 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 or Authorized Representative Signature and Signature Date:

Name:

Phone: 

Address: 


If you are the authorized representative, please fill out the requested information below and sign.

Representative's Name:

Your Relationship to the Beneficiary:

 

 

 

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Scope of Appointment
lock iconUnique Document ID: 58374c4603e3defd9d6ac67f7741b8fd83b29b2e
TimestampAudit
December 5, 2023 2:56 pm PDTScope of Appointment Uploaded by Christopher Wang - docusign@acquirehealthcare.com IP 50.209.61.189