Scope of Appointment (SOA) Form | 360 Degree Insurance Solutions

A Scope of Appointment (SOA) gives me permission to discuss specific Medicare topics with you. Federal regulations require this form before we can meet or speak about Medicare Advantage, Medicare Supplement, or Prescription Drug Plans.

Sales Appointment Confirmation (Scope of Appointment)

Please initial below beside the type of product(s) you want the agent to discuss.

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 (or their authorized representative).

Beneficiary first name *

Beneficiary last name *

Beneficiary phone *

Email *

City *

State *

ZIP *

County *

Medicare Advantage Plans (Part C) and Cost Plans

Medicare 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 your care from doctors or hospitals in the plan’s network (except in emergencies).

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.

Optional Supplemental Dental Plans

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Agreeing to this appointment does not affect your current or future Medicare enrollment status and there is no obligation to enroll. In addition, completing this confirmation will not automatically enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature (type full legal name) *

Signature date *

If you are the authorized representative, please sign above and print below:

Representative’s name

Your relationship to the beneficiary

I agree that typing my name above is my electronic signature. *

Plan Use Only: To be completed by Agent
Agent Name: Sonia Pilar Burke, CA Lic. #4402154 · Agent Phone: (818) 213-0732
Beneficiary name, phone and address; initial method of contact; agent’s signature; date appointment completed; plan(s) represented; and any explanation are completed by the agent.

Sales Appointment Confirmation (Scope of Appointment Form) documentation is subject to CMS record retention requirements.

We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.