Required by Medicare · 60 seconds

Scope of Appointment

Before a licensed advisor can discuss specific plan types, Medicare requires this short permission form. It takes about a minute and does not enroll you in anything.

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). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Which product(s) would you like the agent to discuss?

Medicare Advantage / Prescription Drug Plans (Part C) and Cost Plans

Medicare Preferred Provider Organization (PPO) PlanA Medicare Advantage Plan that provides all Original Medicare Part A and Part B coverage and includes Part D prescription drug coverage. PPOs have network doctors and hospitals, but you can also use out-of-network providers, usually at a higher cost.Medicare Health Maintenance Organization (HMO) PlanA Medicare Advantage Plan that provides all Original Medicare Part A and Part B coverage and includes Part D prescription drug coverage. With most HMOs, you can only get care from doctors or hospitals in the plan's network (except in emergencies).

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP)A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Additional Products

Dental / VisionStand-alone or add-on plans for routine dental and vision care that Original Medicare does not typically cover.Medicare Supplement (Medigap) ProductsSits alongside Original Medicare and helps pay the deductibles, copays, and coinsurance Medicare doesn't cover.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you selected 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 enrollment, or enroll you in a Medicare plan.

Beneficiary information

Beneficiary's full namePhoneAddress (optional)State of residence

I’m signing on behalf of a parent or loved one.Check this if you are an authorized representative completing this form for the Medicare beneficiary.

Type your full name to sign

Signature date: June 5, 2026

I have read and agree to the Scope of Appointment statement above. This does not enroll me in any plan.By checking this box and clicking submit, I agree that Kingdom Health Group and its licensed advisors may contact me by phone, text, and email at the number/email provided, including via automated technology, about Medicare and insurance options. Consent is not a condition of any purchase. Msg & data rates may apply. Reply STOP to opt out. View Privacy Policy and Terms.

Scope of Appointment (SOA) documentation is subject to CMS record retention requirements. Form based on CMS MED-136 (08/28/18).

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-486-2048), 24 hours a day/7 days a week, to get information on all of your options. Not connected with or endorsed by the United States government or the federal Medicare program.

Plan availability varies by area.