Intake Form

    Scope of Sales


    The Centers for Medicare & Medicaid Services requires agents to document the scope of a personal 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.


    Please select the type of products you want the agent to discuss:

    Select below for more information:


    Medicare Advantage Plans (Part C) and Cost Plans


    HMO (Health Maintenance Organization)

    • Usually requires members to use doctors and hospitals
      within the plan's network, except for emergencies or
      other situations allowed by the plan.

    • Members generally select a primary care provider
      who coordinates their care.


    HMO-POS (Health Maintenance Organization – Point of Service)

    • Combines features of an HMO with the ability to receive
      certain services outside the plan's network.

    • Out-of-network services may have higher costs.


    PPO (Preferred Provider Organization)

    • Allows members to receive care from both in-network
      and out-of-network providers.

    • Members generally pay less when using providers
      within the plan's network.


    PFFS (Private Fee-for-Service)

    • Determines how much the plan will pay doctors and
      other healthcare providers and how much the member
      will pay.

    • Members may be able to see providers that accept
      the plan's payment terms.


    SNP (Special Needs Plan)

    • Designed for people with specific health or
      financial circumstances.

    • Includes plans for people who live in institutions,
      have certain chronic conditions, or qualify for
      both Medicare and Medicaid.


    MSA (Medicare Medical Savings Account)

    • Combines a high-deductible Medicare Advantage plan
      with a medical savings account.

    • The plan deposits money into the account to help
      pay for qualified medical expenses.


    Medicare Cost Plan

    • A type of Medicare health plan that may allow members
      to receive services outside the plan's network.

    • Members may return to Original Medicare for
      certain services.


    Stand-alone Medicare Prescription Drug Plans (Part D)


    Medicare Prescription Drug Plan (PDP)

    • A standalone Medicare Part D plan that provides
      prescription drug coverage.

    • These plans are generally used with Original Medicare
      and may also coordinate with certain other
      Medicare coverage.


    Medicare Supplement (Medigap) Products


    Medicare Supplement (Medigap)

    • Private insurance policies that help pay some
      healthcare costs that Original Medicare does not cover.

    • Depending on the policy, this may include certain
      deductibles, coinsurance, and copayments.

    • Medigap policies generally require enrollment in
      Medicare Part A and Part B.


    Dental, Vision, and Hearing Products


    Dental, Vision, and Hearing Products

    • Products that provide additional benefits for dental,
      vision, or hearing services.

    • Coverage and benefits vary depending on the specific
      product and plan.

    • These products may be offered separately from
      Medicare health coverage.


    Hospital Indemnity Products


    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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    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.

    Representative Information


    Medicare Beneficiary Information

    Beneficiary Address

    Get in Touch With Me

    Looking for something?

    We do not offer every plan available in your area. Currently we represent 10 organizations which offer 232 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.