Scope of Sales Appointment Confirmation Form

COMPLETE THE SCOPE OF APPOINTMENT FORM BELOW TO GET STARTED.

Steve Bobrin | 267-498-9704 | sbobrin@dvsa-kba.com

The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of a marketing appointment at least 48 hours prior to any personal marketing meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (you or your authorized representative). The 48-hour rule is waived if the appointment falls within one of the exceptions noted below. A Scope of Appointment Form is required for each beneficiary, and a new form is required if you request information regarding a different plan type than originally agreed upon.

All information provided on this form is confidential and should be completed by your agent at least 48 hours prior to your appointment unless an exception applies.

Select below which plan types you would like to learn more about. By selecting a plan type, you are confirming this form has been completed at least 48 hours prior to the discussion of these benefits unless an exception applies.
Initial here to learn about this.
Initial here to learn about this.
Initial here to learn about this.
Initial here to learn about this.
Initial here to learn about this.

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

Beneficiary or Authorized Representative Signature and Signature Date:
If you are the authorized representative (i.e. Power of Attorney), please sign above and print below:

To be completed by Agent:
Agent Name: Steve Bobrin

Agent Phone: 267-498-9704

Beneficiary Name:

Beneficiary Phone (Optional):

Beneficiary Address (Optional):

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.):

Agent’s Signature:

Plan(s) the agent represented during this meeting:

Date Appointment Completed:

Is the appointment scheduled to be completed prior to the 48-hour waiting period: _______ (Yes/No)
If YES, Exception to the 48-Hour Rule:
____ SOA completed during the last 4 days of a valid election period
____ Beneficiary-initiated walk-in without the availability of a 48-hour waiting period

[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:
 

Sign up for our newsletter

Signup

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.