Scope of Appointment Form | Senior Benefits Unlimited

This form is required by Medicare before discussing specific plan options. Completing this form does not obligate you to enroll in any plan.

Step 1 of 2: Scope of Appointment

To comply with Medicare guidelines, this form must be completed before scheduling your appointment.

Client Information

Full Name Phone Number Email Address Street Address City State ZIP Code

Products to Be Discussed

Please check all that apply:

Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) and Cost Plans Dental/Vision/Hearing Products Hospital Indemnity Products Medicare Supplement (Medigap) Products

RX LIST (Medications)

List current medications. A new row will appear automatically.

Medication

Dosage

Strength

Type

Supply

Preferred Pharmacy

Select Pharmacy

Pharmacy Location (optional) Preferred Supply Type Find lowest-cost pharmacy for my prescriptions

Doctors & Providers

List your primary doctor and any specialists.

Doctor Name

Specialty

Location (City/ZIP)

Appointment Details

Preferred Appointment Date Preferred Appointment Time Meeting Type

Consent and Signature

Electronic Signature (Type Your Full Name) Date Signed

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This form is required by CMS for Medicare Advantage and Part D plan discussions.