Medicare Information

Name

Birthday

Address

County You Live In

Email

Phone

Medicare Part A

Yes

No

Unsure

Medicare Part B

Yes

No

Unsure

Primary Care Doctor

Preferred Hospital

Dentist Name

Vision Provider

Preferred Pharmacy

Specialist Names

Medication Names

How Did You Hear About Us?

If GMS, Employer Name

SCOPE OF 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 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.

I Understand

Medicare requires that licensed agents ensure you that any communications we have focuses only on the type of plan and products you are interested in. Please check the box below that indicates the plan you agree to discuss.

Medicare Advantage Plans

Medicare Supplement

Prescription Card (PDP)

By signing this form, you agree to a meeting or communications with a sales agent to discuss the types of products you indicated 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.

Data Sharing
• Customer data is not shared with 3rd parties for promotional or marketing purposes.
• Mobile opt-in and consent are never shared with anyone for any purpose. Any information sharing that may be mentioned elsewhere in this policy excludes mobile opt-in data.
Messaging Terms and Conditions
• By providing your phone number and agreeing to receive texts, you consent to receive text messages from Medicare Plan Match, from 330-577-1995 regarding customer care. Consent is not a condition of purchase. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time or HELP for assistance. You can also contact us at 330-577-1995 or insres@outlook.com. Mobile opt-in information is never shared with third parties.

I Understand

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

Signature of Medicare Beneficiary Listed on Form

Signature Date

To be Complete by Agent - Agent Name

Agent Phone

Initial Method of Contact

Agent Signature

Plans Represented and Date Appointment Completed