Scope of Appointment Form

Buckley Insurance Group - Scope of Appointment

732-746-3320
Before meeting with a Medicare beneficiary (or their authorized representative) in person or remotely, Medicare requires that Licensed Sales Representatives obtain this form to ensure that only the plans and products Beneficaries agree to are discussed in appointments. Please confirm you agree to discuss these types of plans and products.
Plan Types You Wish to Discuss*

Medicare Advantage Plans (Part C) and Cost PlansStand-alone Medicare Prescription Drug Plans (Part D)Medicare Supplement (Medigap) PlansOther Health Insurance Products, Dental-Vision-Hearing, Hospital Indemnity
Tentative date of appointment with a representative of Buckley Insurance Group is December 07, 2025. After submitting this form you will be able to schedule an appointment on a date and time of your choosing but no sooner that two days from today.

By submitting this form, you agree to meet in person or remotely with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. 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.
Name*

First NameLast Name
Email*
example@example.com
Phone *
Please enter a valid phone number.
Will a spouse/partner/co-habitant also attend the appointment?*

YesNo
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Signature*

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Buckley Insurance Group - Scope of Appointment