Scope of Appointment Confirmation Form

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

For questions about this form, see FAQs below.

* indicates required fields

Select Your Agent

VALERIE

Products to Discuss

Medicare Advantage Plans * Medicare Prescription Drug Plans * Medicare Supplement (Medigap) * Dental/Vision/Hearing Products *

Beneficiary or Authorized Representative Signature and Signature Date:

Signature *

Clear

Date

Representative's Name

Your Relationship to the Beneficiary

Required - to be completed by Agent:

Agent Name *

Agent Phone *

Beneficiary Phone

Medicare ID Number

Beneficiary Address

Initial Contact Method

Beneficiary was a walk-in

Agent Signature *

Plans Represented

PDP MAPD

Date Completed

Plan Use Only

Frequently asked questions

Everything you need to know about All Stages Insurance

When am I eligible to enroll in Medicare?

You are initially eligible to enroll in Medicare during your Initial Enrollment Period (IEP). This is a 7-month window that begins 3 months before the month you turn 65, includes your birthday month, and ends 3 months after your birthday month.

What is the difference between Medicare Advantage and Medigap?

Medicare Advantage (Part C) replaces Original Medicare and often includes built-in prescription drug coverage and extra benefits like dental and vision. A Medicare Supplement (Medigap) plan works alongside Original Medicare to help cover out-of-pocket costs like copayments, coinsurance, and deductibles.

Does it cost anything to use your brokerage services?

No, our advisory and enrollment services are completely free to you. We are compensated directly by the insurance carriers if you choose to enroll in a plan through us. Your premium is exactly the same as if you enrolled directly with the carrier.

Can I change my Medicare plan if my health needs change?

Yes, but generally only during specific times. The Annual Enrollment Period (AEP) runs from October 15 to December 7 each year. You may also qualify for a Special Enrollment Period (SEP) outside of those dates if you experience certain life events, like moving to a new state or losing employer coverage.

Do I need a separate Prescription Drug Plan (Part D)?

If you decide to stay with Original Medicare (or pair it with a Medigap plan), you will typically need to purchase a standalone Part D plan to avoid late enrollment penalties. If you choose a Medicare Advantage plan, most already include built-in prescription drug coverage.

What happens if I work past the age of 65?

If you or your spouse are actively working and you have creditable health coverage through that employer, you can often delay enrolling in Medicare Part B without penalty. We can help you compare your employer coverage to Medicare to see which makes the most financial sense for you.