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Scope of Appointment for Medicare 

** The Scope of Appointment form is a form that must be completed and signed prior to a consultation/appointment to ensure an 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 who has Medicare or their authorized representative.**

Scope of Appointment

1. Please select the product(s) you agree to discuss
2. Your contact Information:
YOU AGREE THAT BY THIS IS A LEGAL REPRESENTATION OF OUR SIGNATURE FOR ALL PURPOSES JUST THE SAME AS A PEN-AND-PAPER SIGNATURE. By digitally 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.
Agent Name : Debbie Smith Agent Email : debbiesmith@pnwinsurancebrokers.com Agent Phone : +1 (509) 344-9855

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