Explore your Medicare coverage options

Seek out various options available and find a plan that fits your budget today. Your health deserves it.

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So we can serve you better, we have a few quick questions for you.

Enter your ZIP code(Required)

Zip Code

Are you currently enrolled in Medicare Parts A & B?(Required)

Yes

Not Sure

What is your age?

Select your age range(Required)

under 65

65 - 69

70 - 79

80 - 89

90 +

Prefer not to say

Age Range

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 face-to-face sales meeting 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.

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

Prescription Drug Plans (part D)

Dental/Vision/Hearing products

Hospital Indemnity products

Critical Illness and Accident Products

Medicare Advantage Plans (part C)

Medicare Supplement (Medigap) products

By typing your first and last name below, you are acknowledging and providing your digital signature. This signature serves as your electronic agreement and confirms your consent to the terms and conditions outlined By signing the form, you agree to a meeting with a sales agent to discuss the types of products you initialed previously. 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 or future enrollment status, or enroll you in a Medicare plan. Scope of Appointment documentation is subject to CMS record retention requirements.

First Name(Required)

Beneficiary Or Authorized Representative

Last Name(Required)

Beneficiary Or Authorized Representative

I am the Authorized Representative

Signature Date

MM slash DD slash YYYY

Email(Required)

Phone Number(Required)

Any Questions or Comments?

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

By entering your information below and clicking Submit, you are giving permission to have a licensed sales agent contact you by email, telephone or cell phone to provide additional information about products and services. Your consent is voluntary and allows us to contact you via email, text messaging, artificial or prerecorded voice messages, or automatic dialing for marketing purposes. You may contact us to change your preferences at any time. Data use charges and rates from your cellular carrier may apply.

This is a solicitation for insurance. By submitting this form, you agree to be contacted by a licensed sales agent to discuss the types of products you selected 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.

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). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

By clicking “Submit” or "Next" above: (1) I agree to receive marketing and other calls, texts and emails, sent to my contact information as entered in this form from Lehigh Partners Senior Benefits, their licensed and other agents/representatives, including by autodialer/pre-recorded message, on a recorded line, even if my number is on a “Do Not Call” list. This consent is voluntary and not required as a condition to buy anything, and can be revoked by calling our 833-265-9655; and (2) I consent and agree to all terms found in the Privacy Policy. If you are Medicare-eligible, a licensed sales agent will contact you about Medicare plan options including Medicare Advantage, Medicare supplement and Prescription Drug plans by phone or email. Submitting this form does NOT affect your current Medicare Part A and Part B enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

I/We do not offer every plan available in your area. Any information I/we provide is limited to the plans I/we do offer in your area. Please contact Medicare.gov or 1-800-Medicare to get information on all of your options

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