Yalonda Scope

Scope of Appointment Confirmation Form
medicare requires that we get your permission to go over plan information

* Indicates required field

Licensed sales representative: *

Yalonda Best

Do you give Yalonda Best permission to contact. *

Yes

Select options 1 & 2 after reviewing *

1. *

Medicare Advantage Plans (Part C) and Cost Plans

2. *

Stand-alone Medicare Prescription Drug Plan (Part D)

Beneficiary Information:

Beneficiary *

Yes, I am the beneficiary No (I am his/her authorized representative (Power of attorney, etc..)

Beneficiary first and last name *

First

Last

Beneficiary phone number *

This is an immediate appointment. Time and date will be stamped on the email that is populated from this form

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email (if you have one) *

Review before signing. *

Beneficiary/Authorized representative signature *

First

Last