Sales Appointment Confirmation Form (SCOPE)

Who is your Insurance Agent? *

Please initial ONE box below beside the plan you want the agent to discuss with you.

Medicare Advantage Plans (Part C)

Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that provides all
Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug
coverage. In most HMOs, you can only go to doctors or hospitals in the plan’s network (except in
emergencies).

Medicare Preferred Provider Organization (PPO) Plan— A Medicare Advantage Plan that provides all
Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug
coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.*

Stand-Alone Medicare Prescription Drug Plan (Part D)

Medicare Prescription Drug Plan (PDP) -- A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost plans, some Medicare Private Fee-for-Service plans, and Medicare Medical Savings Account plans.

Beneficiary Name: *

Beneficiary Phone Number: *

Beneficiary Mailing Address: *

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. 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 compensated 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: *

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Signature Date: