Medicare Intake & Scope of Appointment Form

This form helps your Medicare agent review medications and discuss plan options. Completing this form does not obligate you to enroll.

Client Information

Full Name Date Phone Email Address City State ZIP

Scope of Appointment (Products to Discuss)

Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) and Cost Plans Dental/Vision/Hearing Products Hospital Indemnity Products Medicare Supplement (Medigap) Products

Prescription Medications

#	Medication	Dosage	Strength	Brand/Generic	30/90 Days

Healthcare Providers

Primary Care Doctor Preferred Hospital Specialists

Electronic Signature

Please sign below:

Signature Name (Type Full Name) Date Signed

This form is not a contract and does not obligate enrollment. By submitting, you consent to be contacted by a licensed insurance agent. CMS requires Scope of Appointment documentation before discussing Medicare Advantage or Part D plans.