Insurance Educators - Russell Noel
Scope of Appointment

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual 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.

Who is booking this appointment? *

Beneficiary (Person Receiving Benefits)

Authorized Representative (Person Acting on Behalf of Beneficiary)

Agent

First Name *

Last Name *

Please use the SAME number you entered as Primary Contact Phone on the Information Form. DO NOT ENTER THE SAME NUMBER AS YOUR SPOUSE/FRIEND/FAMILY MEMBER.

Phone *

Please provide the Authorized Representative's full name here. *

What is your relationship to the beneficiary? *

Kindly select ALL of the following products so we can provide the most efficient service: *

Stand-alone 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

Product type descriptions are available at bottom of this page.

Please type your full name. This will serve as your official signature.

Signature *

Signature

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