Scope of Appointment Form

Please fill out this form and get it back to me for any
Part D drug plan or Medicare Advantage plan changes.
I have to keep it on file for 10 years to let the government know I assisted you. 

Click here for the Scope of Appointment Form

1. Put your initials in the box at the top on the plan I'm assisting you with
2. Sign & date at the top Beneficiary Signature Box
3. That's it...I'll fill in the rest for you.