SOA Leave this field blank Beneficiary First Name Beneficiary Last Name Email Address Phone Number Medicare Beneficiary Identifier (optional) Zip Code I am the authorized representative acting on behalf of someone else (For example if you are the Power of Attorney) (optional) Yes No First Name Last Name Relationship Status I am interested in (select all that apply) Prescription Drug Plans (Part D) Dental/Vision/Hearing Products Hospital Indemnity Products Medicare Advantage Plans (Part C) and Cost Plans Medicare Supplement (Medigap) Products Click here to see a glossary of plans and products Digital Signature for Scope of Appointment Please type your name as your signature Beneficiary Or Authorized Representative Please re-type your name as your signature Beneficiary Or Authorized Representative The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any 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. MULTIPLAN_AGAMO202251_M (optional) SUBMIT
