By submitting this form, the individual named below gives permission for Brian Smith, a licensed Medicare insurance agent, to contact them for the purpose of discussing Medicare plan options. This authorization applies solely to the individual and pertains to the types of products selected during the Scope of Appointment process, which may include Medicare Advantage (Part C), Medicare Prescription Drug Plans (Part D), and Medicare Supplement (Medigap) policies.
With this authorization, the agent may:
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Provide information and guidance on Medicare plan options based on the individual’s needs and preferences
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Assist with eligibility verification and enrollment in approved Medicare plans
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Help with updates, changes, or questions related to Medicare coverage
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Use confidential information shared verbally, electronically, or in writing solely for the purposes listed above
All personally identifiable information (PII) will be handled securely and will not be used or disclosed for any purpose other than its intended use. The individual is not required to share any personal or health information beyond what is necessary to evaluate and enroll in a Medicare plan.
This Scope of Appointment remains in effect for the duration of the scheduled appointment, unless revoked. Consent may be withdrawn or modified at any time by replying to this message with “I revoke my consent.”