Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services requires sales agents to document the scope of a marketing appointment prior to any sales meeting, to ensure understanding of what will be discussed between the sales 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.

To be completed by the Beneficiary or Authorized Representative

I understand that this electronic signature on this Scope of Appointment Form (“Form”) means that I have read and understood the contents of this Form. If the Form has the printed name of an authorized representative, the printed name certifies that: 1) This person is authorized under State law to complete this Form, and 2) Documentation of this authority is available upon request.

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

By signing this form, you agree to meeting with a sales agent to discuss the types of products you initiated above. Please note, the person who will discussthe productsis either employed by 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 automatically enroll you in a Medicare Plan.

To be completed by Agent:

Medicare Advantage Prescription Drug Plans (Parts C and D) (HMO)
Medicare Health Maintenance Organization (HMO) - A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and 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 Prescription Drug Plan (PDP) adds prescription drug coverage to Original Medicare.
Medicare Advantage Special Needs Plans (SNPs)
Medicare Advantage Special Needs Plans (SNPs) - Medicare Advantage Plans that provide all Original Medicare Part A and Part B health coverage, and sometimes covers Part D prescription drug coverage, that are specifically designed to provide targeted care and limit enrollment to individuals with special needs. A special needs individual could be an institutionalized individual, a dual eligible individual (eligible for both Medicare and Medicaid) or an individual with a severe or debilitating chronic condition as specified by CMS

Note: Scope of Appointment documentation is subject to CMS record retention requirements.

Sonder Health Plans, Inc. is an HMO with a Medicare contract and a written agreement with Georgia Medicaid program to coordinate Medicaid benefits. Enrollment in Sonder Health Plans, Inc. depends on contract renewal. Sonder Health Plans, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

All SOA forms must be retained by the agent for no less than 10 years and available to Sonder Health Plans upon request regardless of whether or not the appointment resulted in an enrollment.