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Check all the product types you want the agent to discuss. If you are uncertain, select all.
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. By signing 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. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan. By clicking "Submit," you agree to have a licensed sales agent contact you by email, telephone or cell phone to provide additional information about products and services. Your consent is voluntary and allows us to contact you via email, phone or text messaging for marketing purposes. You may contact us to change your preferences at any time.