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Submitted URL: https://www.scope.dollandinsurance.com/
Effective URL: https://form.jotform.com/240285909936165
Submission: On November 20 via api from US — Scanned from DE
Effective URL: https://form.jotform.com/240285909936165
Submission: On November 20 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: form_240285909936165 — POST https://submit.jotform.com/submit/240285909936165
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://submit.jotform.com/submit/240285909936165" method="post" name="form_240285909936165" id="240285909936165"
accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID" value="240285909936165"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden"
id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1731566539632=>init-started:1732130579476=>validator-called:1732130579610=>validator-mounted-false:1732130579611=>init-complete:1732130579617"><input type="hidden"
id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1731566539632"><input type="hidden" name="uploadServerUrl" value="https://upload.jotform.com/upload"><input type="hidden"
name="eventObserver" value="1">
<div id="formCoverLogo" style="margin-bottom:32px" class="form-cover-wrapper form-has-cover form-page-cover-image-align-center">
<div class="form-page-cover-image-wrapper" style="max-width:752px"><img src="https://www.jotform.com/uploads/dollandinsurance/form_files/Logo-01%20%282%29.66c3507a96ba83.91469632.png" class="form-page-cover-image" width="310" height="63"
aria-label="Form Logo" style="aspect-ratio:310/63"></div>
</div>
<div role="main" class="form-all">
<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head" data-css-selector="id_1">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_1" class="form-header" data-component="header">Scope of Appointment Confirmation Form</h1>
</div>
</div>
</li>
<li class="form-line jf-required calculatedOperand" data-type="control_checkbox" id="id_2" data-css-selector="id_2"><label class="form-label form-label-top" id="label_2" aria-hidden="false"> 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 bottom of this page for definitions):<span class="form-required">*</span> </label>
<div id="cid_2" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_2" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_2" type="checkbox"
class="form-checkbox validate[required]" id="input_2_0" name="q2_beforeMeeting2[]" required="" checked="" value="Medicare Advantage plans (Part C) and cost plans"><label id="label_input_2_0" for="input_2_0">Medicare Advantage plans
(Part C) and cost plans</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_2" type="checkbox" class="form-checkbox validate[required]" id="input_2_1"
name="q2_beforeMeeting2[]" required="" checked="" value="Dental-vision-hearing products"><label id="label_input_2_1" for="input_2_1">Dental-vision-hearing products</label></span><span class="form-checkbox-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_2" type="checkbox" class="form-checkbox validate[required]" id="input_2_2" name="q2_beforeMeeting2[]" required="" checked=""
value="Stand-alone Medicare prescription drug (Part D) plan"><label id="label_input_2_2" for="input_2_2">Stand-alone Medicare prescription drug (Part D) plan</label></span><span class="form-checkbox-item" style="clear:left"><span
class="dragger-item"></span><input aria-describedby="label_2" type="checkbox" class="form-checkbox validate[required]" id="input_2_3" name="q2_beforeMeeting2[]" required="" checked="" value="Hospital indemnity products"><label
id="label_input_2_3" for="input_2_3">Hospital indemnity products</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_2" type="checkbox"
class="form-checkbox validate[required]" id="input_2_4" name="q2_beforeMeeting2[]" required="" checked="" value="Medicare Supplement (Medigap) products"><label id="label_input_2_4" for="input_2_4">Medicare Supplement (Medigap)
products</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_3" data-css-selector="id_3">
<div id="cid_3" class="form-input-wide" data-layout="full">
<div id="text_3" class="form-html" data-component="text" tabindex="0">
<p><span style="color: #000000;">By signing this form, you agree to meet with a Sales Agent to discuss the products </span> <span style="color: #000000;">checked above. The Sales Agent is either employed or contracted by a
Medicare plan </span> <span style="color: #000000;">and may be paid based on your enrollment in a plan. Th</span><span style="color: #000000;">ey </span><span style="color: #000000;">do not</span> <span
style="color: #000000;">work directly for the federal </span> <span style="color: #000000;">government.</span></p>
<p><span style="color: #000000;">Signing this form </span><span style="color: #000000;">does not</span> <span style="color: #000000;">affect your current or future enrollment in a Medicare plan, enroll you in a </span> <span
style="color: #000000;">Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is </span> <span style="color: #000000;">confidential.</span></p>
</div>
</div>
</li>
<li id="cid_4" class="form-input-wide" data-type="control_head" data-css-selector="id_4">
<div class="form-header-group header-small">
<div class="header-text httal htvam">
<h3 id="header_4" class="form-header" data-component="header">Beneficiary or authorized representative information</h3>
<div id="subHeader_4" class="form-subHeader">Please use your name and signature if you are the authorized representative. </div>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_40" data-css-selector="id_40"><label class="form-label form-label-top form-label-auto" id="label_40" for="input_40" aria-hidden="false"> Full name<span
class="form-required">*</span> </label>
<div id="cid_40" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_40" name="q40_name" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310"
data-component="textbox" aria-labelledby="label_40" required="" value=""> </div>
</li>
<li class="form-line jf-required" data-type="control_dropdown" id="id_51" data-css-selector="id_51"><label class="form-label form-label-top form-label-auto" id="label_51" for="input_51" aria-hidden="false"> Relationship to beneficiary<span
class="form-required">*</span> </label>
<div id="cid_51" class="form-input-wide jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_51" name="q51_relationshipTo51" style="width:310px" data-component="dropdown" required=""
aria-label="Relationship to beneficiary">
<option value="">Please Select</option>
<option value="Self">Self</option>
<option value="Spouse">Spouse</option>
<option value="Son or daughter">Son or daughter</option>
<option value="Family member">Family member</option>
<option value="Friend">Friend</option>
</select> </div>
</li>
<li class="form-line fixed-width jf-required" data-type="control_signature" id="id_35" data-css-selector="id_35"><label class="form-label form-label-top form-label-auto" id="label_35" for="input_35" aria-hidden="false"> Signature of beneficiary
/ authorized representative<span class="form-required">*</span> </label>
<div id="cid_35" class="form-input-wide jf-required" data-layout="half">
<div data-wrapper-react="true">
<div id="signature_pad_35" class="signature-pad-wrapper">
<div data-wrapper-react="true">
<!--[if IE 7]><script type="text/javascript" src="/js/vendor/json2.js"></script><![endif]-->
</div>
<div class="signature-line signature-wrapper signature-placeholder" data-component="signature">
<div id="sig_pad_35" data-width="550" data-height="150" data-id="35" data-required="true" class="pad validate[required]" aria-description="Use your pointer or touch input to draw your signature." aria-labelledby="label_35"
tabindex="0">
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1em !important; margin-bottom:1em !important;"></div><canvas
class="jSignature" width="550" style="margin: 0px; padding: 0px; border: none; height: 150px; width: 550px; touch-action: none; background-color: rgb(255, 255, 255);" height="150"></canvas>
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1.5em !important; margin-bottom:1.5em !important; position: relative;"></div>
</div><input type="hidden" name="q35_signatureOf35" class="output4" id="input_35">
</div>
<aside class="signature-pad-aside"><span class="clear-pad-btn clear-pad" role="button" tabindex="0">Clear</span></aside>
</div>
<div data-wrapper-react="true">
<script type="text/javascript">
window.signatureForm = true
</script>
</div>
</div>
</div>
</li>
<li class="form-line jf-required calculatedOperand" data-type="control_datetime" id="id_6" data-css-selector="id_6"><label class="form-label form-label-top form-label-auto" id="label_6" for="lite_mode_6" aria-hidden="false"> Today’s date<span
class="form-required">*</span> </label>
<div id="cid_6" class="form-input-wide jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="month_6" name="q6_todaysDate[month]" type="tel" size="2" data-maxlength="2"
data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_6 sublabel_6_month" value="11" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label"
for="month_6" id="sublabel_6_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="currentDate form-textbox validate[required, limitDate]" id="day_6"
name="q6_todaysDate[day]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_6 sublabel_6_day" value="14" inputmode="numeric"><span class="date-separate"
aria-hidden="true"> -</span><label class="form-sub-label" for="day_6" id="sublabel_6_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input
class="form-textbox validate[required, limitDate]" id="year_6" name="q6_todaysDate[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" required="" autocomplete="off" aria-labelledby="label_6 sublabel_6_year"
value="2024"><label class="form-sub-label" for="year_6" id="sublabel_6_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input
class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_6" type="text" size="12" data-maxlength="12" data-age="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY"
data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_6" value="11-14-2024" inputmode="numeric"><img class="showAutoCalendar newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_6_pick"
src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Change date, Wednesday, November 20, 2024" role="button" tabindex="0"
aria-haspopup="dialog" aria-expanded="false"><label class="form-sub-label is-empty" for="lite_mode_6" id="sublabel_6_litemode" style="min-height:13px"></label></span>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_42" data-css-selector="id_42">
<div id="cid_42" class="form-input-wide" data-layout="full">
<div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#8FBDFD;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_47" data-css-selector="id_47">
<div id="cid_47" class="form-input-wide" data-layout="full">
<div id="text_47" class="form-html" data-component="text" tabindex="0">
<p><em>If you are the beneficiary and the appointment is concerning yourself, enter your info below. If you are the authorized representative, enter who this appointment is regarding.</em></p>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_17" data-css-selector="id_17"><label class="form-label form-label-top form-label-auto" id="label_17" for="input_17" aria-hidden="false"> Beneficiary name<span
class="form-required">*</span> </label>
<div id="cid_17" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_17" name="q17_beneficiaryName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px"
size="310" data-component="textbox" aria-labelledby="label_17" required="" value=""> </div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_phone" id="id_48" data-css-selector="id_48"><label class="form-label form-label-top" id="label_48" for="input_48_full"> Beneficiary phone<span
class="form-required">*</span> </label>
<div id="cid_48" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_48_full" name="q48_beneficiaryPhone48[full]" data-type="mask-number"
class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" autocomplete="section-input_48 tel-national" style="width:310px" data-masked="true" placeholder="(000) 000-0000" data-component="phone"
aria-labelledby="label_48" required="" value="" inputmode="text" maskvalue="(###) ###-####"></span> </div>
</li>
<li class="form-line jf-required" data-type="control_address" id="id_46" data-compound-hint=",Apt/Ste/Unit if applicable,,," data-css-selector="id_46"><label class="form-label form-label-top form-label-auto" id="label_46"
for="input_46_addr_line1" aria-hidden="false"> Beneficiary address<span class="form-required">*</span> </label>
<div id="cid_46" class="form-input-wide jf-required" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_46_addr_line1" name="q46_beneficiaryAddress[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_46 address-line1" data-component="address_line_1"
aria-labelledby="label_46 sublabel_46_addr_line1" required="" value="" maxlength="100"><label class="form-sub-label" for="input_46_addr_line1" id="sublabel_46_addr_line1" style="min-height:13px">Street
Address</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container"
style="vertical-align:top"><input type="text" id="input_46_addr_line2" name="q46_beneficiaryAddress[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_46 off"
placeholder="Apt/Ste/Unit if applicable" data-component="address_line_2" aria-labelledby="label_46 sublabel_46_addr_line2" value="" maxlength="100"><label class="form-sub-label" for="input_46_addr_line2"
id="sublabel_46_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_46_city" name="q46_beneficiaryAddress[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_46 address-level2" data-component="city"
aria-labelledby="label_46 sublabel_46_city" required="" value="" maxlength="60"><label class="form-sub-label" for="input_46_city" id="sublabel_46_city" style="min-height:13px">City</label></span></span><span
class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><select class="form-dropdown validate[required] form-address-state"
name="q46_beneficiaryAddress[state]" id="input_46_state" data-component="state" required="" aria-labelledby="label_46 sublabel_46_state" autocomplete="section-input_46 address-level1">
<option value="" selected="">Please Select</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select><label class="form-sub-label" for="input_46_state" id="sublabel_46_state" style="min-height:13px">State</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_46_postal" name="q46_beneficiaryAddress[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_46 postal-code" data-component="zip"
aria-labelledby="label_46 sublabel_46_postal" required="" value="" maxlength="20"><label class="form-sub-label" for="input_46_postal" id="sublabel_46_postal" style="min-height:13px">Zip Code</label></span></span></div>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_datetime" id="id_45" data-css-selector="id_45"><label class="form-label form-label-top form-label-auto" id="label_45" for="lite_mode_45" aria-hidden="false"> Date of appointment </label>
<div id="cid_45" class="form-input-wide always-hidden" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="month_45" name="q45_dateAppointment45[month]" type="tel" size="2" data-maxlength="2"
data-age="" maxlength="2" autocomplete="off" aria-labelledby="label_45 sublabel_45_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="month_45"
id="sublabel_45_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="day_45" name="q45_dateAppointment45[day]"
type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" autocomplete="off" aria-labelledby="label_45 sublabel_45_day" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label
class="form-sub-label" for="day_45" id="sublabel_45_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="year_45"
name="q45_dateAppointment45[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" autocomplete="off" aria-labelledby="label_45 sublabel_45_year" value=""><label class="form-sub-label" for="year_45"
id="sublabel_45_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_45" type="text"
size="12" data-maxlength="12" data-age="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_45" value="" inputmode="numeric"><img
class="showAutoCalendar newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_45_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2"
aria-label="Change date, Friday, November 22, 2024" role="button" tabindex="0" aria-haspopup="dialog" aria-expanded="false"><label class="form-sub-label is-empty" for="lite_mode_45" id="sublabel_45_litemode"
style="min-height:13px"></label></span>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_52" data-css-selector="id_52"><label class="form-label form-label-top form-label-auto" id="label_52" for="input_52" aria-hidden="false"> Initial method of contact </label>
<div id="cid_52" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_52" name="q52_initialMethod" data-type="input-textbox" class="form-readonly form-textbox" data-defaultvalue="Appointment"
style="width:310px" size="310" tabindex="-1" data-component="textbox" aria-labelledby="label_52" readonly="" value="Appointment"> </div>
</li>
<li class="form-line always-hidden" data-type="control_textarea" id="id_53" data-css-selector="id_53"><label class="form-label form-label-top form-label-auto" id="label_53" for="input_53" aria-hidden="false"> Plan(s) the sales agent will
represent during the meeting </label>
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<h3 id="header_28" class="form-header" data-component="header">Medicare Advantage Plans (Part C) and Cost Plans</h3>
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<p><span style="font-weight: bold; color: #000000;">Medicare</span> <span style="font-weight: bold; color: #000000;">Health</span> <span style="font-weight: bold; color: #000000;">Maintenance Organization </span><span
style="font-weight: bold; color: #000000;">(HMO)</span> <span style="color: #000000;">— </span><span style="color: #000000;">A Medicare Advantage plan that provides all </span> <span style="color: #000000;">Original Medicare Part A
and Part B health coverage and sometimes covers Part D prescription drug </span> <span style="color: #000000;">coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network </span> <span
style="color: #000000;">(except in emergencies).</span></p>
<p><span style="font-weight: bold; color: #000000;">Medicare</span> <span style="font-weight: bold; color: #000000;">HMO point</span><span style="font-weight: bold; color: #000000;">-</span><span
style="font-weight: bold; color: #000000;">of</span><span style="font-weight: bold; color: #000000;">-s</span><span style="font-weight: bold; color: #000000;">ervice</span> <span
style="font-weight: bold; color: #000000;">(HMO</span><span style="font-weight: bold; color: #000000;">-</span><span style="font-weight: bold; color: #000000;">POS)</span> <span style="color: #000000;">— </span><span
style="color: #000000;">A Medicare Advantage plan that provides all </span> <span style="color: #000000;">Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug </span> <span
style="color: #000000;">coverage. HMO</span><span style="color: #000000;">-</span><span style="color: #000000;">POS plans may allow you to get some services o</span><span style="color: #000000;">ut of network for a higher </span>
<span style="color: #000000;">copay or coinsurance.</span></p>
<p><span style="font-weight: bold; color: #000000;">Medicare preferred</span> <span style="font-weight: bold; color: #000000;">provider o</span><span style="font-weight: bold; color: #000000;">rganization</span> <span
style="font-weight: bold; color: #000000;">(PPO) Plan</span> <span style="color: #000000;">— </span><span style="color: #000000;">A Medicare Advantage plan that provides </span> <span style="color: #000000;">all Original Medicare Part
A and Part B health coverage and sometimes covers Part D prescription </span> <span style="color: #000000;">drug </span><span style="color: #000000;">coverage. PPOs have network doctors, providers and hospitals but you can also use
out</span><span style="color: #000000;">-</span><span style="color: #000000;">of-</span><span style="color: #000000;">network providers, usually at a higher cost.</span></p>
<p><span style="font-weight: bold; color: #000000;">Medicare private fee-f</span><span style="font-weight: bold; color: #000000;">or</span><span style="font-weight: bold; color: #000000;">-s</span><span
style="font-weight: bold; color: #000000;">ervice (PFFS) plan</span> <span style="color: #000000;">— </span><span style="color: #000000;">A Medicare Advantage plan in which you may go </span> <span style="color: #000000;">to any
Medicare</span><span style="color: #000000;">-</span><span style="color: #000000;">approved </span><span style="color: #000000;">doctor, hospital and provider that accepts the plan’s payment, terms and </span> <span
style="color: #000000;">conditions and agrees to treat you </span><span style="color: #000000;">— </span><span style="color: #000000;">not all providers will. If you join a PFFS Plan that has a network, </span> <span
style="color: #000000;">you can see any of the network providers who have agreed to always treat plan members. You will </span> <span style="color: #000000;">usually pay more to see out</span><span
style="color: #c4c4c4;">-</span><span style="color: #000000;">of-</span><span style="color: #000000;">network providers.</span></p>
<p><span style="font-weight: bold; color: #000000;">Medicare </span><span style="font-weight: bold; color: #000000;">Special </span><span style="font-weight: bold; color: #000000;">Needs</span> <span
style="font-weight: bold; color: #000000;">Plan (SNP) </span><span style="color: #000000;">— </span><span style="color: #000000;">A Medicare Advantage plan that has a benefit package </span> <span style="color: #000000;">designed for
people with special health care needs. Examples of the specific groups served include </span> <span style="color: #000000;">people who have both Medicare and Medicaid, people who reside in nursing homes, and people </span> <span
style="color: #000000;">who have certain chronic medical conditions.</span></p>
<p><span style="font-weight: bold; color: #000000;">Medicare</span> <span style="font-weight: bold; color: #000000;">Medical </span><span style="font-weight: bold; color: #000000;">Savings </span><span
style="font-weight: bold; color: #000000;">Account</span> <span style="font-weight: bold; color: #000000;">(MSA)</span> <span style="font-weight: bold; color: #000000;">Plan</span> <span style="color: #000000;">— </span><span
style="color: #000000;">MSA plans combine a high deductible health </span> <span style="color: #000000;">plan with a bank account. The</span> <span style="color: #000000;">plan deposits money from Medicare into the account. You can
use it </span> <span style="color: #000000;">to pay your medical expenses until your deductible is met.</span></p>
<p><span style="font-weight: bold; color: #000000;">Medicare </span><span style="font-weight: bold; color: #000000;">Cost</span> <span style="font-weight: bold; color: #000000;">Plan</span> <span style="color: #000000;">— </span><span
style="color: #000000;">In a Medicare cost plan, you can go to providers both in and out of network. If </span> <span style="color: #000000;">you get services outside of</span> <span style="color: #000000;">the plan’s network, your
Medicare</span><span style="color: #000000;">-</span><span style="color: #000000;">covered services will be paid for under </span> <span style="color: #000000;">Original Medicare but you will be responsible for Medicare coinsurance
and deductibles.</span></p>
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<h3 id="header_30" class="form-header" data-component="header">Stand-alone Medicare Prescription Drug Plans (Part D)</h3>
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</div>
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<div id="text_31" class="form-html" data-component="text" tabindex="0">
<p><span style="font-weight: bold;color: #000000;">Medicare</span><span style="font-weight: bold;color: #000000;"> </span><span style="font-weight: bold;color: #000000;">Prescription </span><span
style="font-weight: bold;color: #000000;">Drug</span><span style="font-weight: bold;color: #000000;"> </span><span style="font-weight: bold;color: #000000;">Plan</span><span style="font-weight: bold;color: #000000;"> </span><span
style="font-weight: bold;color: #000000;">(PDP)</span><span style="font-weight: bold;color: #000000;"> </span><span style="color: #000000;">— </span><span style="color: #000000;">A stand-</span><span style="color: #000000;">alone drug
plan that adds prescription drug </span> <span style="color: #000000;">coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-</span><span style="color: #000000;">Fee</span><span
style="color: #000000;">-</span><span style="color: #000000;">For</span><span style="color: #6e6e6e;">-</span><span style="color: #000000;">Service </span> <span style="color: #000000;">Plans, and Medicare Medical Savings Account
Plans.</span></p>
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<h3 id="header_32" class="form-header" data-component="header">Other Related Products</h3>
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<p><span style="font-weight: bold;color: #000000;">Medicare Supplement (Medigap) Products</span><span style="color: #000000;">— </span><span style="color: #000000;">Insurance plans that help pay some of the</span><span
style="color: #000000;"> </span><span style="color: #000000;">out</span><span style="color: #c5c5c5;">-</span><span style="color: #000000;">of-</span> <span style="color: #000000;">pocket costs not paid by Original Medicare (Parts A
and B) such as deductibles and co</span><span style="color: #000000;">-</span><span style="color: #000000;">insurance </span> <span style="color: #000000;">amounts for Medicare approved services.</span></p>
<p><span style="font-weight: bold;color: #000000;">Dental/Vision/Hearing Products</span><span style="font-weight: bold;color: #000000;"> </span><span style="color: #000000;">— </span><span style="color: #000000;">Plans offering additional
benefits for consumers who are </span> <span style="color: #000000;">looking to cover needs for dental, vision, or hearing. These plans </span><span style="font-weight: bold;color: #000000;">are not</span><span
style="color: #000000;"> </span><span style="color: #000000;">affiliated or connected to </span> <span style="color: #000000;">Medicare.</span></p>
<p><span style="font-weight: bold;color: #000000;">Hospital Indemnity Products</span><span style="color: #000000;">— </span><span style="color: #000000;">Plans offering additional benefits; payable to consumers based </span> <span
style="color: #000000;">upon their medical utilization; sometimes used to defray copays/coinsurance. These plans </span><span style="font-weight: bold;color: #000000;">are not</span> <span style="color: #000000;">affiliated or
connected to Medicare.</span></p>
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* SCOPE OF APPOINTMENT CONFIRMATION FORM * 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 bottom of this page for definitions):* Medicare Advantage plans (Part C) and cost plansDental-vision-hearing productsStand-alone Medicare prescription drug (Part D) planHospital indemnity productsMedicare Supplement (Medigap) 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 INFORMATION Please use your name and signature if you are the authorized representative. * Full name* * Relationship to beneficiary* Please Select Self Spouse Son or daughter Family member Friend * Signature of beneficiary / authorized representative* Clear * Today’s date* -Month -DayYear * * If you are the beneficiary and the appointment is concerning yourself, enter your info below. If you are the authorized representative, enter who this appointment is regarding. * Beneficiary name* * Beneficiary phone* * Beneficiary address* Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code * Date of appointment -Month -DayYear * Initial method of contact * Plan(s) the sales agent will represent during the meeting * Sales agent name * Sales agent ID * Sales agent phone * Submit * * MEDICARE ADVANTAGE PLANS (PART C) AND COST PLANS * Medicare Health Maintenance Organization (HMO) — 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) — 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 PLANS (PART D) * Medicare Prescription Drug Plan (PDP) — A stand-alone 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 (Parts A and B) such as deductibles and co-insurance 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. * Should be Empty: November‹› 2024«» November 2024TodaySMTWTFS27282930311234567891011121314151617181920212223242526272829301234567891011121314 November‹› 2024«» November 2024TodaySMTWTFS27282930311234567891011121314151617181920212223242526272829301234567891011121314