Medicare Part D

Scope of Appointment Confirmation Form
Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires
that Licensed Sales Representatives use this form to ensure your appointment focuses only on the
type of plan and products you are interested in. A separate form should be used for each Medicare
beneficiary.
The licensed Sales Representative will go over the below health products:
Medicare Advantage Plans (Part C) and Cost Plans
Stand-alone Medicare Prescription Drug Plan (Part D)
Medicare Supplement (Medigap) Plans
Dental-Vision-Hearing Products
Hospital Indemnity Products

By signing this form, you agree to meet with a Licensed Sales Representative to discuss the
products checked above. The Licensed Sales Representative is either employed or contracted by a
Medicare plan and may be paid based on your enrollment in a plan. They do NOT work directly for
the federal government.
Signing this form does NOT affect your current or future enrollment in a Medicare plan, enroll you in
a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is
confidential.
Beneficiary or Authorized Representative Signature and Signature Date:

Your Name : Robert Vombaur
Your Email : Cvombaur@gmail.com
accepted Date Signed: 2024-04-23