Scope of Appointment Form

To be completed by person with Medicare:

Please initial below in the box beside the plan type that you want the agent to discuss with you.
If you do not want the agent to discuss a plan type with you, please leave the box empty.

Medicare Advantage (Part C), Medicare Advantage Prescription Drug Plans, and other Medicare Plans

By signing this you are agreeing to a sales meeting or call with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing plan options with you is either employed or contracted by a Medicare health plan or prescription drug plan that is not the Federal government, and they may be compensated based on your enrollment in a plan

Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

* Required

Beneficiary Name *
Phone: *

Medicare Part A Medicare Part B State Health Plan from the Government of PR. (Reforma) *

Beneficiary Physical Address:

If you are an authorized representative, you should sign above and provide the following information:

Name of authorized representative:
Phone
Relationship to Beneficiary: