Scope of Appointment for Lisa Chamberlain

Scope of Appointment Confirmation Form
Medicare requires Licensed Sales Representatives to document the scope of an appointment prior to any sales meeting to ensure understanding of what will be discussed between them 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 beneficiary.
To ensure your appointment focuses only on those Medicare and health-related products you want to discuss with your licensed sales representative, please indicate by checking the appropriate box(es) beside the product(s) in which you are interested.
x Stand-alone Medicare Prescription Drug Plans
x Medicare Advantage Plans (Part C) and Cost (Pard D) Plans
x Dental/Vision/Hearing Products
x Hospital Indemnity Products
x Medicare Supplement or (Medigap) Products

By signing this form, you agree to a meeting with a Licensed Sales Representative to discuss the types of products you checked above. Please note, the person 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 Medicare enrollment, or enroll you in a Medicare plan.
Beneficiary or Authorized Representative Signature and Signature Date:

To be completed by Licensed Sales Representative
Licensed Sales Representative Name: Lisa Chamberlain; Phone: 801-609-8699;
Licensed Sales Representative ID: 414474;
Beneficiary Name:
Beneficiary Phone:
Date appointment will be completed:
Initial method of contact:
Plans the Licensed Sales Representative will represent during the meeting:
Licensed Sales Representive Signature: Lisa Chamberlain
Scope of appointment (SOA) is subject to Medicare Record Retention Requirements.
Licensed Sales representative: If applicable, please explain why SOA was not documented and signed by beneficiary prior to meeting. Check all that apply.
___ Unplanned Attendee
___ New SOA required (consumer requested other Health Product information)
___ Walk-in
___ Other (please explain)