Medicare

Scope of Appointment

Federal law requires a signed Scope of Appointment before we can discuss Medicare Advantage, Part D, or Medigap plans with you. Complete your portion below and sign with your finger or mouse. It takes about two minutes.

Required by CMS

Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services (CMS) 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.

Prefer paper? Download SOA Form

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

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

Medicare Preferred Provider Organization (PPO) PlanA 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.Medicare Health Maintenance Organization (HMO) PlanA 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)

Medicare Prescription Drug Plan (PDP)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

Ancillary ProductsDental, Vision, Hearing, Cancer Policies, and Indemnity Policies.Medicare Supplement (Medigap) Products

Your Information

First Name

Last Name

Phone

Email (optional)

Home Address

Authorized Representative (optional)

Only complete this section if you are signing on behalf of the person with Medicare. Most people leave it blank.

Representative's Name

Your Relationship to the Beneficiary

By signing this form, you agree to a meeting with a 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.

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

Your Signature

Sign inside the box with your finger or mouse.

Sign here

Signature Date: 09/18/2026

The agent section of this form is completed by your Medical Benefits Network agent after we receive your submission.