Medicare Scope of Appointment

Before we discuss specific Medicare Advantage or Prescription Drug Plan options, Medicare rules require us to document what you agree to talk about during the appointment.

What this form does

This Scope of Appointment form tells TCG Insurance Solutions which Medicare-related products you want to discuss. It does not enroll you in a plan, does not obligate you to buy anything, and does not affect your current or future Medicare enrollment.

Important: During the appointment, we may only discuss the product types you select below unless you request additional information and a new Scope of Appointment is completed when required.

Please do not enter your Medicare number, Social Security number, prescription list, medical conditions, banking information, or other private health information on this form.

Complete Your Scope of Appointment

Fields marked with * are required.

Beneficiary Information

First Name *
Last Name *
Phone *

Email *

City *

State *

ZIP Code *

Appointment Information

Appointment Date *

Appointment Time *

Appointment Method *

Products You Agree to Discuss *

Please select only the products you want to discuss during this appointment.

Medicare Advantage Plans — Part C
Medicare health plans offered by private companies that contract with Medicare.

Medicare Prescription Drug Plans — Part D
Plans that help cover prescription drug costs.

Medicare Supplement Insurance — Medigap
Policies that may help pay certain out-of-pocket costs with Original Medicare.

Dental, vision, and hearing coverage
Additional coverage options that may be available separately or with certain plans.

Authorized Representative, if applicable

Representative Name

Relationship to Beneficiary

Representative Phone

Scope of Appointment Agreement

I agree to the Scope of Appointment. *
I understand that by signing this form, I am agreeing to meet with Paul Carrigan / TCG Insurance Solutions to discuss only the product types selected above. I understand there is no obligation to enroll, my current or future Medicare enrollment status will not be affected, and I will not be automatically enrolled in any plan.

Electronic Signature *

Signature Date *

Optional Note or Question

Agent Information

Paul Carrigan
TCG Insurance Solutions
Website: www.TCGsolutions.us
Phone: 913-837-0434
Email: TCGinsurancesolutions@gmail.com

Required TPMO Disclaimer

We do not offer every plan available in your area. Currently we represent 5 organizations which offer 34 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Privacy & use of this form

This form is used to document what Medicare products you agreed to discuss.
Completing this form does not enroll you in a Medicare plan.
Please do not submit Medicare numbers, Social Security numbers, prescription lists, banking information, or medical details through this form.
For questions, contact TCG Insurance Solutions before submitting the form.

Scope of Appointment