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Scope of Appointment

Confirmation Form

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sales meeting to ensure 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. By signing this form, you agree to meet with Kim Killman to discuss the products listed below. Kim Killman is contracted by Medicare plans and may be paid based on your enrollment in a plan. She does NOT work directly for the federal government.

We will be able to discuss the following options:

Signing this form does NOT affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential and HIPAA compliant.

Beneficiary First & Last Name *

Beneficiary Address *

Beneficiary Phone *

Beneficiary Email *

Beneficiary or Authorized Representative Signature and Signature Date:

Date Signed *

Relationship to Beneficiary *

AGENT INFORMATION

Licensed Sales Representative: Kim Killman

Licensed Sales Representative Phone: 405-802-2426

Licensed Sales Representative Email: [email protected]

Licensed Sales Representative ID: 3002792267

Date Appointment Completed: ___________________________________

Agent Signature____________________________________________

This website contains information that can direct you to Medicare advisement services. In compliance with CMS rules & regulations for Medicare, please note that this is a solicitation for insurance. Submitting information or calling numbers listed on this website will direct you to a licensed Agent/Broker. Important disclosures about Medicare Plans: Medicare has neither endorsed nor reviewed this information. Not connected or affiliated with any United States Government or State agency. 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 to get information on all of your options.

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