Medicare Consent Form

Scope of Appointment Consent Form

Thank you for choosing Synergy Benefit Advisors. We are required to obtain and document your consent 48 hours before discussing Medicare coverage options. Please complete and submit the Scope of Appointment form below to authorize us to speak with you about Medicare products. Once we receive your completed consent form, we will be able to proceed and provide you with the information you need to make the right decisions for your healthcare needs. Scope of Appointment forms are valid for 12 months and must be completed annually. Thank you for your cooperation.

 

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment before any sales meeting to ensure an understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Medicare Advantage Plans (Part C)

Medicare Advantage Plans, also known as Medicare Part C, combine the benefits of Medicare Parts A, B and typically D. Medicare Advantage plans are sold and administered by private health insurance companies that have contracts with the Federal government. Medicare Advantage Plans typically come with additional benefits that Original Medicare doesn’t have. In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, which could help protect you from unexpected costs.

Examples of Medicare Advantage Plans include:

  • Medicare Health Maintenance Organization (HMO) Plan – Provides all the
    benefits of Original Medicare and sometimes includes Part D prescription drug
    coverage. In most HMOs, you can only get your care from doctors or hospitals in
    the plan’s network (except in emergencies).
  • Medicare Preferred Provider Organization (PPO) Plan – Provides all the
    benefits of Original Medicare and sometimes covers Part D prescription drug
    coverage. PPOs have network doctors and hospitals but you can also use out-of-
    network providers, typically at a higher cost.
  • Medicare Private Fee-For-Services (PFFS) Plan – A plan that allows you to
    go to any Medicare-approved doctor, hospital and provider that accepts the
    plan’s payment, terms and conditions to treat you. If your PFFS plan has a
    network, you can see any of the network providers who have agreed to treat
    members of the plan. You typically will pay more for out-of-network providers.
  • Medicare Special Needs Plan (SNP) – A plan that has specific benefits
    intended for people with special health needs. Examples of special health needs
    include people who qualify for both Medicare and Medicaid, people in nursing
    homes, and people with approved chronic health conditions.

Medicare Supplement (Medigap) Products

Medicare Supplement Plans, also known as Medigap, are secondary insurance policies that helps fill "gaps" in Original Medicare and are sold by private companies. A Medicare Supplement insurance policy can pay some or all of the deductible and co-insurance amounts that are not covered by Medicare.

Stand-alone Medicare Prescription Drug Plan (Part D)

A stand-alone Medicare Part D plan adds prescription drug insurance to Original Medicare, some Medicare PFFS plans. Medicare Drug Plans are sold and administered by private insurance companies that have contracts with the Federal government and benefits can vary from company to company.

Ancillary Products

You can get ancillary products through private insurance companies. These plans offer additional benefits to people who want separate coverage for things like dental, vision and hearing. Ancillary plans are not Medicare products.

Authorized Representative

An Authorized Representative is a person chosen by a Medicare beneficiary to help with Medicare-related matters, such as the following: researching and choosing Medicare coverage. handling Medicare claims and payments. and appealing Medicare coverage decisions.
By law, Medicare must have written permission from the primary Medicare beneficiary (an “authorization”) to use or give out personal medical information for any purpose that isn't set out in the privacy notice contained in the Medicare & You handbook. The primary Medicare beneficiary may take back (“revoke”) their written permission at any time, except if Medicare has already acted based on your permission. For more details, please visit medicare.gov
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