Medicare Advantage Plan Quote

Scope of Sales Appointment Confirmation Form

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 Medicare beneficiary or his/her authorized representative. Agents must be licensed, contracted, and certified, where applicable, to sell each of the plans listed below.

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Name *

First

Last

Email *

Zip Code *

Date of Birth *

Phone *

When would you like to talk to an agent? *

Date

Time

Choose Any *

Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Advantage Plans (Part C) and Cost Plans
Dental/Vision/Hearing Products
Medicare Supplement (Medigap) Products

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Initials *

Comment

DISCLAIMER: By submitting this form, you agree to a phone meeting with a licensed health insurance agent with Insurance Secure Plus LLC to discuss the type of products you initialed above. Please note, the person who will discuss the products is a licensed agent either employed or contracted by a Medicare plan. They do not work directly for the Federal government. By providing your information in the form above you expressly consent to receive information from Lapeira & Associates LLC via phone call, email and/or text/SMS message (including through the use of an automatic telephone dialing system or artificial/prerecorded voice, SMS or MMS (text) messages, even if your telephone number(s) is/are currently listed on any state, federal or corporate Do Not Call list). Standard text message rates and cellular data charges may apply. The licensed health insurance agent may be also paid based on your enrollment in a plan. Your consent in this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Consent *

I understand and agree with the disclaimer above.

🔒 Your information is secure. *

I agree to receiving marketing and promotional materials

Medicare Advantage Plan Quote

Scope of Sales Appointment Confirmation Form

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