Required Authorization

Scope of Appointment (SOA) & Permission to Discuss Form

Instructions for the Consumer:

The Centers for Medicare & Medicaid Services (CMS) requires licensed insurance agents to document the specific product types a consumer agrees to discuss prior to any scheduled appointment. This protection ensures that no unrequested or unexpected insurance products are presented to you during your meeting.

Please check the boxes next to the product types you give the agent permission to discuss with you. Checking a box does NOT obligate you to enroll in a plan, change your current coverage, or purchase any policy.

1. Select the Insurance Products You Authorize for Discussion:

Medicare Advantage (Part C) & Prescription Drug Plans (Part D) Description: Includes private health plans (HMO, PPO, PFFS) that replace Original Medicare, as well as standalone prescription drug policies designed to reduce out-of-pocket medication expenses.

Hospital Indemnity Insurance Description: Supplemental policies that pay fixed cash benefits directly to you for qualifying inpatient hospital stays to help absorb deductibles, copayments, or non-medical daily costs.

Cancer Insurance Description: A specialized supplemental plan that pays a direct lump-sum cash benefit upon a verified diagnosis of covered cancer strains to help pay for experimental treatments or household bills.

Critical Care / Critical Illness Insurance Description: Provides standalone lump-sum financial support upon the sudden diagnosis of specified severe medical events, such as a major heart attack, stroke, or complete organ failure.

2. Consumer Acknowledgment & Authorization

By signing below, you explicitly acknowledge that you have requested this meeting and permit the licensed agent to discuss only the specific insurance product categories you selected above. You understand that the agent is legally prohibited from presenting or discussing any product types you left unchecked.

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

Full Name (Electronic Signature)

Email Address

Phone Number

Date

3. Agent Documentation (To be completed by Agent)

Agent Printed Name

Agent National Producer Number (NPN)

Agent Signature

Licensed Agent Contact Information: Phone: 227-997-7132 Email: sbsseniorconsulting@gmail.com

Date of Scheduled Appointment

Method of Presentation

In-Person Telephonic Interview Virtual / Video Conference