Scope of Work Form - Funk and Zoltek Healthcare Benefits Advisors

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Sales Agents use this form to ensure your appointment focuses only on the type of plans and products you are interested in. A separate form should be used for each Medicare beneficiary. Please check below to acknowledge you want to discuss all topics with the Sales Agent

Medicare Advantage (Part C) plans and cost plans, Standalone Medicare prescription drug (Part D) plans, Medicare Supplement (Medigap) products, Dental, vision, hearing products and Hospital indemnity products

By signing this form, you agree to meet with a Sales Agent to discuss the products checked above. The Sales Agent is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is
confidential.

Current Date and Time:

Date

Time

Beneficiary Address

Address Line 1

Address Line 2

City

State

Zip Code

below: authorized Beneficiary

Signature of beneficiary/authorized representative

Clear Signature

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

First

Last

Relationship to Beneficiary

Proceed to the SUBMIT button at the bottom. All fields below this point will be filled out by a licensed healthcare agent.

Only to be completed by licensed sales representative

Sales Agent Name

Sales Agent Phone

Sales Agent ID

Beneficiary Name

Beneficiary Phone

Date of Appointment

Initial Method of Contact

Plan(s) the sales Agent will represent

Sales Agent Signature

Clear Signature