SOA Form

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.
Plans to Discuss

Agreement

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.
This field is for validation purposes and should be left unchanged.

Meds

  • Prescription Information

    Please list all current prescription medications as listed on your medication bottles. List only medications prescribed by your doctor. Exclude over-the-counter items. Please list the generic name if you take generic medications. If you are taking injectables / inhalers / eyedrops / cremes, please list the number of vials / inhalers / bottles / tubes you use per month.
  • Pharmacy Information

  • Additional Comments

    *Please use this section to identify any additional medications if you have more than 10.
  • Authorization

    I have willingly provided the health information on this page to Seniormark, LLC, to assist in my selection of an individual health plan. I am seeking their recommendation for a Medicare plan that will meet my needs. This is a solicitation of insurance. By providing this information, I agree that an authorized representative or licensed insurance agent/producer may contact me by phone, e-mail, or mail to answer my questions or provide additional information about Medicare Supplement Insurance, Medicare Advantage, or Part D plans. I understand the information on this form is not to be used for any purpose other than to assist in my Medicare health plan selection, I am not bound to accept their recommendation, and this service is offered at no cost to me. This authorization expires 120 days after my signature date.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.