2022 Lycoming Tioga MA Kit

Scope of Sales Appointment Confirmation Form The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any sales meeting to ensure understanding of what will be discussed between the agent and the Medicare bene˜ciary (or his or her authorized representative). All information provided on this form is con˜dential and should be completed by each Medicare bene˜ciary or his or her authorized representative. All elds on this form must be completed. Please initial in the box at the left to con rm that you will be discussing Medicare Advantage plans with the agent. See page 2 for Medicare Advantage plan descriptions. By signing this form, you agree to a meeting with a sales agent to discuss Medicare Advantage plans. Please note, the person who will discuss the product is either employed or contracted by a Medicare plan. The individual does 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 automatically enroll you in a Medicare plan. Beneficiary or authorized representative signature and signature date: Signature: Signature date: If you are the beneficiary’s authorized representative, please sign above and print below: Representative’s name: Your relationship to the beneficiary: To be completed by agent: Agent name: Agent phone: Beneficiary name: Beneficiary phone: Beneficiary address: Date of appointment: Agent’s signature: SOA documentation is subject to CMS record retention requirements. Page 1 of 2 Enrollment 137 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111