Scope of Appointment - All Stages Insurance
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Scope of Appointment Confirmation Form

All Stages Insurance Solutions LLC | Valerie Shamim, Licensed Insurance Broker

The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting so there is a clear understanding of what will be discussed between the agent and the Medicare beneficiary or authorized representative. All information provided on this form is confidential.

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.

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Select Your Agent

VALERIE

Products to Discuss

Beneficiary Or Authorized Representative Signature And Signature Date:

If You Are The Authorized Representative(Power Of Attorney) Completing This On Behalf Of The Beneficiary, Please Complete Below.

Required - to be completed by Agent:

Plan(s) The Agent Represented During This Meeting

Prepare for Your Appointment

Help us tailor your coverage options before your appointment.

Complete the Pre-Appointment Form so we can have your prescriptions, providers, and preferences ready. Fill it out before your visit or submit it in advance to save time. Need help? Contact us!

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Pharmacy & Prescriptions

Check all pharmacies you're willing to use for cost savings on prescriptions

Prescription *

Click or tap the plus (+) button to add multiple prescriptions.

Medicare Extra Help Program

For the purposes of the Medicare Extra Help Program, please tell us if your annual income is below $23,475 for an individual or $31,725 if married. *

If Interested In Medicare Advantage Plans

Hospital Preference and Primary Care Dr are required when Medicare Advantage Plans are selected on Step 1.

Specialist And Specialty

Click or tap the plus (+) button to add multiple specialists.

Check All Products You Would Like Information About

Would You Like Information About

During our appointment, CMS marketing rules prohibit any discussion of the following products. If you have questions about or are interested in any of the following, please check the box:

Preferred Contact Method *

Would You Like To Add An Emergency Contact? *

Frequently asked questions

Everything you need to know about All Stages Insurance

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.
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.
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.
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.
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.
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.