Scope of Appointment

A Scope of Appointment form is required in all personal or individual face-to-face appointments where MA, MA-PD, PDP, and Cost Plan products are to be discussed with Medicare beneficiaries.

Please complete the form below.

Scope of Appointment Form - Agents Dave Trout, David Hanson & Idelle Davids

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. Fields marked with an asterisk (*) are required.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated 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.

* Indicates required field

Beneficiary or Authorized Representative Signature *

Date of Signature *

Agent Name(s): Dave Trout, David Hanson, Idelle Davids
Agent Phone Number: 828-658-1472

Beneficiary Name *

First

Last

Beneficiary Phone *

Beneficiary Address *

Line 1

Line 2

City

State

Zip Code

Country

Plans Represented During the Meeting: MAPD, PDP, Dental/Vision/Hearing Products

Date Completed *

Submit

We do not offer every plan available in your area. Currently we represent at least 8 organizations which offer at least 57 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Scope of appointment

Scope of Appointment Form - Agents Dave Trout, David Hanson & Idelle Davids

SUBSCRIBE!