Medicare Scope of Appointment

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.
Please indicate the type of product(s) you want the agent to discuss.

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* Do you want to discuss Medicare Advantage Plans (Part C)?

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* Do you want to discuss Prescription Drug Plans (Part D)?

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* Do you want to discuss Medicare Supplement or Medigap Plans?

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* Do you want to discuss Dental/Vision/Hearing Products?

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* I agree to a meeting with a sales agent from Westhouse Agency, LLC to discuss the types of products I agreed to above.  The person with whom I will discuss these 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 my enrollment in a plan.  Completing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment status or enroll you in a Medicare plan.

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* Entering my name here serves as my signature

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* Current Home Address

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* Phone Number

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* You have finished your Survey.  The remaining entries are reserved for AGENT USE ONLY.  Please scroll to bottom and click DONE.

         Agent Name:                                           
         Agent Phone:  616-970-2503           
         
         Initial Method of Contact:                             
         
         Plans Represented:                                                               
         Date of Appointment:

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