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Sales Appointment
Confirmation Form
(8.5 X
11 Adobe Acrobat version of Confirmation Form)
Please initial
below in the box beside the insurance product type(s) that you want
Jim to discuss with you. If you wish to open the possibility of
discussing all items listed, check the first box, “00”.
 (00) Please come prepared to discuss all
products listed
Discuss all
products – No further
boxes need be checked. Please go to page 2 and sign and date
(01) Stand-alone Medicare Supplement Plans
Please initial
below in the box beside the insurance product type(s) that you want
Jim to discuss with you. If you do not want Jim to discuss a
particular product with you, please strike through the plan
description.
(02) Stand-a-lone Medicare Prescription Drug Plan
(Part D)
Medicare
Prescription Drug Plan (PDP) -
A standalone drug plan that adds
prescription drug coverage to the Original Medicare Plan, some
Medicare Cost Plans, some Medicare Private Fee-for-Service Plans,
and Medicare Medical Savings Account Plans.
(03) Medicare Advantage (Part C), Medicare
Advantage Prescription Drug Plans, and other Medicare Plans
Medicare Health Maintenance
Organization (HMO) - A
Medicare Advantage Plan that must cover all Part A and Part B health
care. In most HMOs, you can only go to doctors, specialists, or
hospitals in the plan's network except in an emergency.
Medicare Preferred Provider
Organization (PPO) Plan -
A type of Medicare Advantage Plan
available in a local or regional area in which you pay less if you
use doctors, hospitals, and providers that belong to the network.
You can use doctors, hospitals and providers outside of the network
for an additional cost.
Medicare Private Fee-For-Service (PFFS)
Plan - A type of Medicare
Advantage Plan in which you may go to any Medicare-approved doctor
or hospital that accepts the plan's payment and terms and
conditions.
Medicare Special Needs Plan (SNP) -
A special type of
Medicare Advantage Plan that provides more focused and specialized
health care for specific groups of people, such as those who have
both Medicare and Medicaid, who reside in a nursing home, or have
certain chronic medical conditions.
Medicare Medical Savings Account (MSA)
Plan - MSA Plans combine
a high deductible Medicare Advantage Plan and a bank account. The
plan deposits money from Medicare in the account. You can use it to
pay your medical expenses until your deductible is met.
Medicare Cost Plan -
A type of health plan. In a Medicare
Cost Plan, if you get services outside of the plan's network
without a referral, your Medicare-covered services will be paid for
under the Original Medicare Plan (your Cost Plan pays for emergency
services, or urgently needed services.
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(04)Long Term Care Insurance
Long Term
Care Insurance – An
insurance plan that pays for in-home care expenses, nursing home
expenses and other expenses not paid by Medicare
(05) Life Insurance
Life
Insurance – An insurance
plan that pays a death benefit on the insured’s death
(06) Annuities
Annuities
– Tax
advantaged cash savings plans or
asset distribution plans
Jim works with
many insurance companies that offer some or all the products
described in the preceding.
Many companies
offer Medicare-approved HMOs with a Medicare Advantage Prescription
Drug Plan (MA-PD) contract, open to all Medicare beneficiaries who
reside within the plan's service area and are entitled to Medicare
Part A and Part B. The plan's prescription benefit is only available
to enrollees of the MA-PD plan. Benefits vary by geographic area.
You must receive all routine care from network providers. If you
obtain routine care from out-of-network providers, neither Medicare
nor the Medicare Advantage Prescription Drug Plan will be
responsible for the costs.
Some companies offer
Medicare-contracted prescription drug plans, open to all Medicare
beneficiaries who reside within the plan's service area and are
entitled to Medicare Part A or enrolled in Medicare Part B. Benefits
vary by plan. In some plans you must use network pharmacies to
access your prescription drug benefit, except under non-routine
circumstances when you cannot reasonably use network pharmacies.
Other plans have no network pharmacy restrictions.
You must continue to pay your Medicare
Part B premium if not otherwise paid for under Medicaid or by
another third-party. Minimal copayments, restrictions and
limitations apply. Issuing insurance companies have a contract with
the federal government that is renewed annually and the availability
of coverage beyond the end of the current contract year (2009) is
not guaranteed.
By signing this form you are only
agreeing to a sales meeting with Jim Spahr to discuss the specific
types of products you initialed above. Jim is contracted with many
Medicare health plans and/or prescription drug plans. Jim is
not contracted with or an agent
of the Federal government. If you enroll in a plan presented by Jim,
he will be compensated by the insurance company/plan provider based
on your enrollment in a plan.
Signing this form does NOT affect your current enrollment nor will it
enroll you in a Medicare Advantage Plan, Prescription Drug Plan,
other Medicare plan or obligate you in any way to purchase any
product discussed. Neither does your signature obligate you to any
fee payment. In other words, you may walk away from this meeting
without any obligation to Jim or any insurance company.
Beneficiary signature:
___________________________ date/time: _______________
Beneficiary address:
____________________________________________________
Beneficiary phone:
___________________ Initial contact method: ________________
______________________________
date/time: _____________
s/Jim Spahr
Referred by:
___________________________________________________
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