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 an 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. 
Fields marked with a red asterisk (*) are required.

NOTE: A 48-hour waiting time is required before an agent can review Medicare Plans with you. An appointment should be scheduled 48 hours or more after the date and time you submitted this SOA

Please check one or ALL the product(s)  below (If you do not check all products, and a question comes up about one product that you did not check, another SOA would be required. So I recommend you check all four products)

___ Stand-alone Medicare Prescription Drug Plans (Part D)
___ Medicare Advantage Plans (Part C) and Cost Plans
___Medicare Supplement (Medigap) Products
___ Ancillary Products

Please complete the required information as indicated by an asterisk *

Beneficiary’s First Name*

Beneficiary’s Last Name*

*Address (Line 1)



*Zip Code

Are you the authorized representative acting on behalf of the beneficiary? Yes or No (ignore this unless you are representing someone else – like your mother, father, relative, friend, etc.)

___ By checking this box, I have read and understand the contents of the Scope of Appointment form, and I confirm that the information I have provided is accurate. If submitted by an authorized individual (as described above), this submission certifies that 1) this person is authorized under State law to complete the Scope of Appointment form, and 2) documentation of this authority is available upon request by Medicare. (Check this and “Submit” to complete)