The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face 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. This is not an enrollment form.

Please put your initials besides the products you would like to discuss with the authorized representative:

Medicare Advantage Plans (Part C)

Health Maintenance Organization (HMO):
A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get our care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Preferred Provider Organization (PPO):
A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Special Needs Plan (SNP):
A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

By completing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed 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. Completing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

I authorize to be contacted by Constellation Health. *