SOA for Medicare - The Cronin Agency

We do not offer every plan available in your area. Currently we represent 12 organizations which offer 72 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Comments

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

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.

A new SOA is required if the beneficiary requests information regarding a different plan type than previously agreed upon.

Place a check next to the type of product(s) you want the agent to discuss: (Note: View complete Medicare Product Descriptions on page 2)

☐ Stand-alone Medicare Prescription Drug Plans (Part D)
☒ Medicare Advantage Plans (Part C)
☐ Medicare Supplement (Medigap) Products
☐ Ancillary Products (Dental/Vision/Hearing Products)

Beneficiary or Authorized Representative Information:

By digitally signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated 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.

There is no obligation to enroll. Current or future Medicare enrollment status will not be impacted, and automatic enrollment will not occur.

Name(Required)

First Last

Date(Required)

Time(Required)

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

Representative Name

Relationship to the Beneficiary

To be completed by Agent. All fields are required.

Agent Name:

Agent Phone:

Beneficiary Name:

First Last

Beneficiary Phone:

Beneficiary Address (include City, State, and ZIP Code):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Initial Method of contact:

In Person

Telephone

Walk-In

Other

Agents Signature:

Plan(s) the agent represented during this meeting

Date Appointment Completed::

Scope of Appointment documentation is subject to CMS record retention requirements and is completed and submitted for all scheduled appointments (including no-shows, cancelled appointments, and for those that do not result in a sale).