Medicare Help from Experts | Lehigh Partners

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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

Are you signing for yourself, or is an authorized representative signing for you?(Required)

I am signing for myself

I am signing as an authorized representative

First Name(Required)

Beneficiary Or Authorized Representative

Last Name(Required)

Beneficiary Or Authorized Representative

Signature Date

MM slash DD slash YYYY

Email(Required)

Phone Number(Required)

Any Questions or Comments?

By typing your first and last name above, 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.

Date of Appointment: or later.

This form does not replace or constitute an appointment with a licensed agent. It exists only for the purpose of collecting information prior to your future appointment with the agent so that the agent may prepare in advance and assist you best during your appointment. If you have any questions about this form or do not have all of this information available, it is okay to wait until your appointment to discuss further with your agent.

🔒 A licensed agent will personally review your answers — no robocalls, no spam.

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Scope of Sales Appointment Confirmation Form

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