Scope of Appointment Confirmation Form

The Centers for Medicare and Medicaid Services (CMS) requires licensed sales agents to document the scope of the products that may be presented during a marketing appointment between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential. A separate form should be completed for each Medicare eligible beneficiary or his/her authorized representative.

 

Please indicate the product(s) you agree to discuss by checking the applicable checkbox(es):​​

​

​

​

​

​​

 

​

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

 

Signing this form does not obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

 

Beneficiary or Authorized Representative Signature and Signature Date:

​

​

​

​

​

​

​​

If you are the authorized representative, please sign above and print below:

 

                                                                                                 

 

 

 

To be completed by the Agent (print clearly and legibly):

*Scope of Appointment documentation is subject to CMS record retention requirements*

Agent Name: Daphne Roberson, Madison Levins, Margaret Gorham

Agent Phone: 860-379-6700           Agent Writing Number: 6372998, 18938362, 19423718

Beneficiary Name:                                                Phone (Optional:                                     Date Appointment will be Completed: 10/15/2025

Beneficiary Address (Optional):

Initial Method of Contact: Phone          Plan(s) the Agent will represent during the meeting: MAPD, PDP, Med Supplement

Agent’s Signature: Daphne Roberson, Madison Levins, Margaret Gorham

​

If applicable, provide the explanation why the SOA was not signed prior to meeting:

• Unplanned Attendee Walk-in

• Other (please explain):

• Beneficiary requested other health-related product information

 

Currently we represent 11 organizations which offer 60 products in your area. You can always contact Medicare.gov, 1-800- MEDICARE, or your local State Health Insurance Assistance Program (SHIP) for help with plan choices.

** Please note, this is a mandatory Medicare Disclosure, keep in mind as a fiduciary we will make recommendations with your best interests in mind.