Scope of Appointment

This is a short form CMS requires before any licensed agent can discuss specific Medicare plan options with you. It just confirms what you'd like to talk about — it does not enroll you in anything or obligate you in any way.

Your information

This should match the person attending the appointment.

Full name *

Phone *

Address *

Appointment date *

Appointment type *

What would you like to discuss? *

Check everything you're open to hearing about. This is the only thing that gives Trevor permission to discuss it — anything not checked is off-limits for this appointment.

Medicare Advantage plansHMO, PPO, and similar Medicare Advantage plans Medicare Prescription Drug PlansStandalone Part D coverage Medicare Supplement (Medigap)Plans that work alongside Original Medicare Dual Eligible Special Needs PlansFor people who qualify for both Medicare and Medicaid Other ancillary coverageDental, vision, hearing, hospital indemnity, or similar

You can always add more topics at a future appointment with a new form — this one only covers what's checked above, for the appointment on the date listed.

Sign & confirm

Typing your name below counts as your electronic signature for this form.

Type your full name to sign *

I agree to a Medicare sales appointment with Trevor Snell (NPN 5457367) to discuss only the topics I checked above. Completing this form does not obligate me to enroll in anything, does not affect my current coverage, and is not required to get information. This is not connected with or endorsed by Medicare or any government agency.

Once this is live inside GHL, submissions here get logged straight to your CRM (with a timestamped copy kept for the 10-year retention requirement) instead of the email fallback below.

Thanks — this appointment is scoped.

Email a copy to Trevor

Why we ask for this: CMS requires a Scope of Appointment before a licensed agent can discuss specific Medicare plan options, so both sides are clear on what's being covered. As of June 1, 2026, CMS no longer requires this to be signed a set number of hours in advance — it just has to be completed before any plan-specific discussion begins, which is why this can be filled out right up to the start of the appointment. [Placeholder — confirm final required wording and any additional carrier/FMO-specific timing rules with your compliance contact before this goes live; some carriers may still ask for their own advance notice.]

Trevor Snell Insurance · NPN 5457367 · Utah Lic. #131223 · 801-654-2313 · 4335 S Noal Dr, Millcreek, UT 84124. Records are retained for 10 years as required. This form is not an application for insurance and does not affect any current coverage.

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. Trevor Snell Insurance is not associated with or endorsed by Medicare, the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (DHHS) or any other government agency. Medicare has neither reviewed nor endorsed this information. For a complete listing of plans in your area please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.