Please Fill Out Your Scope of Appointment

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual 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. By signing this form, you agree to meet with David Raigoza to discuss the products listed below. David Raigoza is contracted by Medicare plans and may be paid based on your enrollment in a plan. He does NOT work directly for the federal government.

We will be able to discuss the following options:

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 and HIPAA compliant.

Beneficiary First & Last Name *

Beneficiary Address *

Beneficiary Phone *

Beneficiary Email

Beneficiary or Authorized Representative Signature and Signature Date:

Beneficiary Signature *

Clear

Date Signed

Relationship to Beneficiary

Agent Information

Licensed Sales Representative: David Raigoza

Licensed Sales Representative Phone: 210-574-7860

Licensed Sales Representative Email: [email protected]

Licensed Sales Representative ID: 2261621

Date Appointment Completed: ___________________________________

Agent Signature____________________________________________