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How to Get Started

To request your Medicare Planning Options Analysis, please complete the 3-step form on this page. Please be advised if you leave the page before finishing the final step, your progress will not be saved.
If you would prefer to download fillable forms click here.

How to Get Started

How To Get Started

To request your Medicare Planning Options Analysis, please complete the multi-step form on this page. Please be advised if you leave the page before finishing the final step, your progress will not be saved.
If you would prefer to download fillable forms click here.

    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). 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(s) you want the agent to discuss.
    Product type descriptions can be found at the bottom of this page.

    Standalone Medicare Prescription Drug Plans (Part D)

    Medicare Advantage Plans (Part C) and Cost Plans

    Dental/Vision/Hearing Products

    Hospital Indemnity Products

    Medicare Supplement (Medigap) Products

    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 and Signature Date:
    Signature - Sign Below with Cursor Or Touch (Touch Screen Devices)
    Signature Date
    If you are the 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 (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:

    [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:

    Personal Information Sheet

    Complete the Following:
    Name:
    DOB:
    Phone:
    Address:
    City:
    County:
    State:
    ZIP:
    Email:
    Tobacco Use Last 12 Months?
    Referred By
    What coverage do you currently have?
    Mark the Box that Applies
    Plan Name
    Drug Coverage Included?
    OR
    Medicare Advantage Plan Name (HMO/PPO) (on your Insurance Card)
    OR
    Medicare Supplement Company Name (on your Insurance Card)
    Type: (F/G/Other)
    AND
    Plan Name of Current Prescription Drug Coverage (on your Insurance Card)
    Do you have Medicare?
    Mark here if you have a MY MEDICARE.gov account set up
    Veteran?
    Interested in a Plan with Health Club Membership?
    Disclaimer: Sharing this information with us is strictly voluntary. The information is used to create a more accurate plan analysis based on your specific needs as presented by Medicare’s Official Website.

    Personal Information Sheet Continued

    Please complete the following:
    Current Pharmacy Name/Mail Order (very important)

    Personal Information Sheet Continued

    Please complete the following:
    Primary Care Dr. Name:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Medications- We must know exact information to get an accurate drug analysis
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    We will utilize a screen share to review your analysis. Please mark ALL devices you have available:
    Disclaimer: Sharing this information with us is strictly voluntary. The information is used to create a more accurate plan analysis based on your specific needs as presented by Medicare’s Official Website.