LLC
MEDICARE & SUPPLEMENTAL ("GAP")
Insurance Plans
SCOPE OF APPOINTMENT
CONFIRMATION FORM
Medicare requires Licensed Sales Representatives to document the scope of an appointment prior to any sales meeting to ensure understanding of what will be discussed between them and the Medicare beneficiary (or their authorized representative).
All information provided on this form is confidential. A separate form should be completed for each Medicare beneficiary.
You may complete this form online. When you click the "Send and Request Appointment" button at the bottom of the page, a copy of this form will be emailed to Insurance Solutions LLC and to you.
You can also download this form and return a signed copy by email to info@ineedaplan.com or by fax to (203) 256-9524.
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Upon receipt of your appointment request, this web form or PDF form will be appended with additional information such as the Licensed Sales Representative's name, phone number, and Agent ID, the initial method of contact, the plans to be discussed, the date of the appointment and agent signature.
Scope of Appointment (SOA) is subject to CMS (Medicare) Record Retention Requirements.
If applicable, Licensed Sales Representative must explain why SOA was not documented and signed by beneficiary prior to meeting.
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you select below. 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 or future enrollment, or enroll you in a Medicare plan.