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We have a couple of optional questions to help provide you with plan options. Upon completion of this short form, I’ll contact you to discuss plan options in your area and answer any questions!

By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone, text, or email regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Providing permission does not impact eligibility to enroll or the provision of services.

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American Senior Benefits and is a licensed health insurance agency and agent who is not affiliated or endorsed by the government or Federal Medicare program.

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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 visit Medicare.gov or call 1-800-MEDICARE to get information on all of your options.

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American Senior Benefits represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

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Do not include over-the-counter medications, vitamins, supplements, or specialty drugs administered at your doctor's office or facility.

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To provide plan options in your area, We’ll need some info on your doctors and preferred hospital(s) to verify their network status.

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Scope of Sales Appointment Confirmation Form

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The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

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Please initial on the type of product(s) you want the agent to discuss with you.

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CMS requires your initials before we can provide you plan options in your area. Click "Next" to get started on this final part.


Medicare Advantage Plans (Part C) and Cost Plans

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Medicare Health Maintenance Organization (HMO)- A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).Text

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Legal: By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone, text, or email regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Providing permission does not impact eligibility to enroll or the provision of services.


American Senior Benefits and is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program. 


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 visit Medicare.gov or call 1-800-MEDICARE to get information on all of your options.


American Senior Benefits represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.


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Once submitted, please allow up to 2 business days for your agent to review the information. If support was requested, they will be in touch with you to gather the additional details. We look forward to supporting you in your insurance needs and will be in touch with you soon!

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National Producer Number for Carol Mitchell: 16015827

ASB of Arkansas and Carol Mitchell is NOT AFFILIATED with any Government Agency.

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, or your local state health insurance program, (SHIP) to get more information on your options.

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