Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Sales Agents 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. Please check what you want to discuss with the Sales Agent (See the back of this page for definitions):

Medicare Advantage (Part C) plans and cost plansStandalone Medicare prescription drug (Part D) plansMedicare Supplement (Medigap) productsDental, vision, hearing productsHospital indemnity products

By signing this form, you agree to meet with a Sales Agent to discuss the products checked above. The Sales Agent 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:
* Signature of beneficiary/authorized representative

If you are the authorized representative, please sign above and print clearly and legibly below:
*Name
*Relationship to beneficiary
To be completed by licensed sales representative (please print clearly and legibly)
*Sales Agent name
* Sales Agent phone


*Sales Agent ID
*Beneficiary name
* Beneficiary phone


*Date of appointment
*Beneficiary address
*Initial method of contact
*Plan(s) the Sales Agent will represent during the meeting
*Sales Agent signature

Medicare Advantage plans (Part C) and cost plans
Medicare Health Maintenance Organization (HMO) plan
-A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).
Medicare HMO point-of-service (HMO-POS) plan
-A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription
drug coverage. HMO-POS plans may allow you to get some services out of network for a higher copay or coinsurance.
Medicare preferred provider organization (PPO) plan
-A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors, providers and hospitals but you can also use out-of-network providers, usually at a higher cost.
Medicare private fee-for-service (PFFS) plan
-A Medicare Advantage plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan's payment, terms and conditions and agrees to treat you -not all providers will. If you join a PFFS plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.
Medicare Special Needs Plan (SNP)
-A Medicare Advantage plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes and people who have certain chronic medical conditions.
Medicare Medical Savings Account (MSA) plan
-MSA plans combine a high-deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.
Medicare cost plan
-In a Medicare cost plan, you can go to providers both in and out-of-network. If you get services outside of the plan's network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Stand-alone Medicare prescription drug (Part D) plan
Medicare prescription drug plan (PDP) -A standalone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare private fee-for-service plans and Medicare Medical Savings Account Plans.

Other related products
Medicare Supplement (Medigap) Products
-Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare Part A and Part B, such as deductibles and coinsurance amounts for Medicare approved services.
Dental, vision, hearing products
-Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.
Hospital indemnity products -Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare.

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