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Scope of Appointment Request Form

The Centers for Medicare & Medicaid Services (CMS) requires American Health Advantage of Texas (HMO I-SNP) to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or his/her authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

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Yes, I would like to discuss American Health Advantage of Texas's Medicare Advantage Prescription Drug Benefit Plan. American Health Advantage of Texas Medicare Institutional Special Needs Plan (I-SNP) - A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. This plan is available to anyone with Medicare who meets an institutional level of care and resides in a participating nursing home.

Name

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Last

Phone

Best Time to Call

Today's Date

Signature

Checking this box will serve as your electronic signature *

By signing this form, you agree to a meeting with an American Health Advantage of Texas license sales agent to discuss the American Health Advantage of Texas Medicare Advantage/Prescription Drug Benefit Plan. Please note, the person who will discuss the plan is either employed or contracted by American Health Advantage of Texas. The person does not work directly for the Federal government. This individual may also be paid based on your enrollment in the plan.

Signing this form does NOT obligate you to enroll in American Health Advantage of Texas (HMO I-SNP) or affect your current or future Medicare enrollment status.

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

Authorized Representative Name

First

Last

Beneficiary Name

First

Last

Relationship to Beneficiary

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I agree. Please contact me.

Scope of Appointment Request Form

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