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Medicare Scope of Appt

Priority Health Medicare Scope of Appointment Form

The Centers for Medicare and Medicaid Services (CMS) 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 (and his/her authorized representative). All information provided on this form is confidential. If you do not want the agent to discuss a plan type with you, please leave the box empty. 

Below are detailed descriptions of the various plans.  
Medicare Advantage plans (Part C)

Medicare Health Maintenance Organization Point of Service (HMO-PSO) - A Medicare Advantage Plan that provides all Original Medicare Part A & Part B health coverage and sometimes covers Part D prescription drug coverage. With the HMO-POS plan, you must use our plan providers to get your covered services at the highest benefit level except in limited circumstances such as an emergency. Under the POS, or out-of-network coverage, you may see any provider who accepts Medicare payments within the United States and its territories. However, you will pay slightly more for most services. 

Medicare Preferred Provider Organization (PPO) Plan - A Medicare Advantage Plan that provides all Original Medicare Part A & Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can use out-of-network providers with no prior authorization required on most services, usually at a higher cost. 
Dental/Vision/Hearing Products

Plans offering additional dental, vision, and/or hearing benefits for consumers looking for this coverage. These plans are not affiliated with or connected to Medicare. 
Ancillary Products

Plans offering additional benefits; payable to consumers based on their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare. 
Medicare supplement plans (Medigap products)

Plans offering a supplemental policy to fill "gaps" in Original Medicare coverage. A Medigap policy typically pays some or all of the deductibles and coinsurance amount applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside the country. These plans are not affiliated or connected to Medicare. NOTE: a Medigap plan cannot be used with a Medicare Advantage plan. 
Prescription Drug Plan (PDP) Part D

Stand-Alone prescription drug coverage - not available as a stand- alone from Priority Health.
Dual Eligible Special Needs Plan (D-SNP)

This plan has both Medicare and full Medicaid benefits. Please note, you must have full Medicaid benefits for this plan to be an option. Only select this box if instructed to by your agent. 
1. Please check the box of the product(s) you want the agent to discuss. *This question is required.
We will use this email address to send Medicare plan information ONLY - your email will not be sold or used for other marketing purposes.  This question requires a valid email address.
4. By electronically signing this form, you agree to discuss with a sales agent the types of products checked above. Please note, the person who will discuss the 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 your enrollment in a plan. 

Signing this form electronically does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan. 

Please use your mouse if on a desktop, or a stylus or finger if on a touchscreen, to write your signature in the box below. Type the name of the person who signed the form - either the beneficiary or an Authorized Representative - in the box below the signature block for verification. 

Beneficiary or Authorized Representative signature: *This question is required.
Signature of
Please copy and paste the email address out of the email you received with the link to this form. This question requires a valid email address.
Beneficiary phone & address (optional)
Initial method of contact
Agent Signature
Signature of