Complete the Following:
MM slash DD slash YYYY
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 individual sales meeting to ensure understanding of what will be discussed between theagent 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. A new SOA is required if the beneficiary requests information regarding a different plan type than previously agreed upon.

Place a check next to the type of product(s) you want the agent to discuss:
(Note: Product type descriptions can be found at the bottom of this page.)
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed 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.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Signature - Sign Below with Cursor Or Touch (Touch Screen Devices)
MM slash DD slash YYYY
If you are the authorized representative, please sign above and print below:
This field is for validation purposes and should be left unchanged.

Product Type Descriptions

Scope of Appointment documentation is subject to CMS record retention requirements and is completed and submitted for all scheduled appointments (including no-shows, cancelled appointments, and for those that do not result in a sale).

Have more questions? get in touch