Before your appointment

Your Scope of Appointment

Medicare asks you to confirm what we’ll discuss before we meet. Read the form below, then enter your details and sign in the fields underneath it — about two minutes.

Step 1 of 2 — just read this

The official form (a picture you read only)

Below is the Medicare Scope of Appointment. It is here only so you can read it — like a photo of the paper form. You cannot type or write on it. When you have finished reading, go down to Step 2, where you type your answers into the boxes and sign.

This is only a picture — you can’t type here. Your boxes to fill in are further down the page.

Hard to read? You can open a bigger copy to read here — that copy is just for reading too. You always type your answers in Step 2 below.

Step 2 of 2 — type your answers here

Fill in the boxes below and sign

This is where you type. Signing only confirms what we’ll talk about — it does not enroll you in anything.

What would you like to talk about?

Tap all that apply — at least one.

Prescription drug coverageStand-alone Medicare Prescription Drug Plans (Part D)All-in-one Medicare plansMedicare Advantage Plans (Part C) and Cost PlansDental, vision, or hearingDental / Vision / Hearing ProductsExtra coverage for out-of-pocket costsSupplemental Health ProductsMedigap supplement plansMedicare Supplement (Medigap) Products

Your full name

Email (we send your copy here)

Re-type your email

Phone

Mailing address

Your date of birth

Medicare eligibility and timing depend on this — and it lets me send reminders at the right time for you.

Month

Day

Year

How did you first reach us? (optional)

I’m signing on behalf of someone else (I’m their authorized representative)

Yes, I’d like Barb to email me helpful Medicare reminders and seasonal updates. This is separate from signing the form, and I can unsubscribe anytime with one click.

Type your full name to signBy typing my name I electronically sign this Scope of Appointment, with the same legal effect as a handwritten signature. Signing does not obligate me to enroll in any plan.