MEDICARE APPOINTMENT CONSENT

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 individual 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.

Below are the type of product(s) your agent will discuss.

Stand-alone Medicare Prescription Drug Plans(Part D)

Advantage Plans (Part C) and Cost Plans Dental/Vision

Hospital Indemnity Products Medicare Supplement

Other:

By signing this form, you agree to a meeting with a agent to discuss the types of products. 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. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative : XXXX

Date:

OFFICE USE ONLY  

Agent Name:

Agent Phone:

Beneficiary Name: Beneficiary Phone:

Beneficiary Address:

Initial Method of Contact:

(Indicate here if beneficiary was a walk-in.)

Agent’s Signature:

Plan(s) the agent represented during this meeting:

Date Appointment Completed: [Plan Use Only:]

 Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting: Scope of Appointment documentation is subject to CMS record retention requirements Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. Y0001_4011_7653 Accepted 05/2016.