Scope of Appointment

Scope of Sales Appointment Confirmation Form

A requirement from CMS before we can discuss any Medicare options.(If using a tablet or mobile device, rotate the screen horizontally)

Background:

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment before any individual 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.

Please initial below beside BOTH fields to discuss any Medicare coverage option with you.

Initials ONLY

Medicare Advantage Plans (Part C), many plans also include prescription drug coverage (Part D)

Initials ONLY

Stand-alone Medicare Prescription Drug Plan (Part D) to compliment Original Medicare

Meeting

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. 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 compensated based on your enrollment in a plan.

No obligation to enroll

Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.

Your Information - please follow the field instructions below

Person's name on the Medicare plan

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

County

Area Code & Phone Number: Person with the Medicare plan or their POA

Email: Person with the Medicare plan or their POA

Type your name as your signature (If POA, add your relationship after your name)

KBellbenefits, LLC, 55 Sewilo Hills Drive, Rochester, NY 14622

Phone: 585-298-2700

Please read:

Click the Submit button below, and a thank you message will appear.

If the form does not submit, please scroll back up and look for the red text below the field that requires correction. Please use dashes in the phone number field (xxx-xxx-xxxx), which is the most common error experienced. Submit the form after the field has been corrected.