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 2
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 HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

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.

Beneficiary or Authorized Representative Signature:

 


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 15, 2021