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 face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative).

Scope of Sales Appointment - Virtual Part 1
All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Please initial below beside the type of product you want the agent to discuss.

Medicare Advantage Prescription Drug Plan

Medicare Special Needs Plan (HMO SNP)—A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.
Medicare Advantage Plans (Part C) provide all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most MOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this Scope of Sales Appointment Form means that I have read and understand the contents of this form, I agree to meet with a sales agent and discuss the types of products initialed above, and understand that the person who will discuss the products is either employed or contracted by a Medicare plan and does not work directly for the federal government. Signing this form does NOT obligate me to enroll in a plan, affect my current enrollment, or enroll me in a Medicare Plan.

If signed by an authorized representative (as described above), this signature certifies that:

  1. This person is authorized under state law to complete an enrollment, and
  2. Documentation of this authority is available upon request by Medicare.
 

To be Completed by Agent

(include area code)
(include area code)
Indicate if beneficiary was a walk-in
 

Plan Use Only

Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting.

*Scope of Appointment documentation is subject to CMS record retention requirements*

Nascentia Health Plus is an HMO SNP plan with a Medicare contract and a Coordination of Benefits Agreement with New York State. Enrollment in Nascentia Health Plus depends on contract renewal.

Last Updated on October 10, 2022