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Scope of Appointment for Medicare

Name: PNW Insurance Brokers
Address: 1603 E Francis Ave, Spokane, WA, 99208, US
Telephone: (509) 344-9855

** 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

STAND-ALONE MEDICARE PRESCRIPTION DRUG PLANS (PART D) 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.

MEDICARE ADVANTAGE PLANS (PART C) A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage.

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.

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.

2. Your contact Information:

Beneficiary First Name Beneficiary Last Name

Beneficiary Email

Beneficiary Phone

Your Relationship To Beneficiary

3. Beneficiary or Authorized Representative Signature:

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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Scope of Appointment for Medicare

Scope of Appointment

Anytime I have questions I get a response quickly.

I’m saving hundreds of dollars a year on my insurance now.

I'm for a long and mutually enjoyable relationship.

You are the best!

You have exceeded our expectations...

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