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Contact Me / Scope of Appointment Request Form

The Centers for Medicare & Medicaid Services (CMS) requires Missouri Medicare Select Representatives 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.

Yes, I would like to discuss Missouri Medicare Select’s Medicare Advantage Prescription Drug Benefit Plan. Missouri Medicare Select is a 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.

You have my permission to contact me at the phone number below.

By signing this form, you agree to a meeting with a Missouri Medicare Select Representative to discuss the Missouri Medicare Select Medicare Advantage Prescription Drug Benefit Plan. Please note, the person who will discuss the plan is either employed or contracted by Missouri Medicare Select. 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 Missouri Medicare Select or affect your current or future Medicare enrollment status.

Beneficiary or Authorized Representative Signature and Signature Date:

Checking this box will serve as your electronic signature

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