Scope of Appointment

This is a required form confirming which Medicare products you want to discuss. Complete it before a meeting that will discuss specific Medicare Advantage or prescription drug (Part D) products. It is not an enrollment and not a plan recommendation. For an education-only Zoom, talk with Alan instead — this form is not required.

Agent: Alan Blackwell · Licensed Medicare Insurance Agent 0M71640

First name *Last name *Email *Phone *ZIP code *

Products I agree to discuss *

Check only what you want to talk about. We will not discuss Medicare Advantage or Part D products you do not check. Medigap is not part of this form.

Medicare Advantage (Part C) without prescription drugsMedicare Advantage with prescription drug coverage (MAPD)Stand-alone Medicare Prescription Drug Plan (Part D)Dual Eligible Special Needs Plan (D-SNP)Chronic Condition Special Needs Plan (C-SNP)

Preferred appointment (optional)Electronic signature (type your first and last name) *I agree that my typed name is my electronic signature on this Scope of Appointment. I understand this is not an enrollment. The agent may discuss only the products I checked. *I consent to be contacted by Alan Blackwell of Medisure Agency at the phone number and email provided, including via automated dialing or pre-recorded messages. Consent is not a condition of enrollment. Message and data rates may apply. *I also consent to receive text messages (SMS) about my Medicare options. Reply STOP to unsubscribe at any time. This is optional and separate from phone consent.

We are not affiliated with or endorsed by the U.S. Government or the federal Medicare program. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week. If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.