Scope of Appointment

The Centers for Medicare & Medicaid Services (CMS) requires that before I discuss Medicare health or drug plans with you, I document the products you’d like to talk about. This is called a Scope of Appointment. It ensures our conversation stays focused on what matters to you and that I don’t discuss anything you haven’t asked about.

This is a marketing appointment — not a Medicare-sponsored event. It is not connected with or endorsed by the U.S. government or the federal Medicare program.

This form is voluntary. You are not required to complete it, and doing so does not obligate you to enroll in any plan. Your selections simply tell me what we may discuss together.

First Name *

Last Name *

Email *

Phone Number *

Appointment Type *

Products to discuss (select all that apply) *

Medicare Advantage (MA)

Medicare Advantage with RX (MAPD)

Part D Prescription Drug Plan (PDP)

Medicare Supplement (Medigap)

Check if agreed *

I agree this is a marketing appointment and I wish to discuss only the product type(s) I selected above. I am not required to complete this form, and this does not obligate me to enroll in any plan.*

Check if agreed *

I understand that by typing my full legal name and submitting this form, I am providing my electronic signature under the U.S. E-Sign Act, and that this Scope of Appointment will be recorded with the date and time of submission.*

Sign your full legal name *

Clear

Enter your full legal name *

* Some VPNs may block form submissions. If successful, you'll see a confirmation message immediately after submitting.

NOTE: You may change or cancel this scope at any time before the appointment.

I do not offer every plan available in your area. Currently I represent 6 insurance carriers, and the number of products available varies by county.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.

MAYST LLC dba Medicare Precision is owned and operated by Evette Eickelmann, a licensed independent AHIP-certified Medicare insurance agent based in Cuba, Missouri, and is not connected with or endorsed by the U.S. government or the federal Medicare program.

I follow Medicare’s official rules for when and how I can review and compare specific Medicare plan options, including only discussing and enrolling in plans during the Medicare enrollment periods for which you are eligible.

I do not offer every plan available in your area. Currently I represent 6 insurance carriers, and the number of products available varies by county. To schedule an appointment to discuss the plan options available in your county, please contact me through my Contact page.

Please contact Medicare.gov, 1-800-MEDICARE (1-800-633-4227), or your local State Health Insurance Program (SHIP) to get information on all of your options. In Missouri, go to MissouriSHIP.org.

Services are available only to Missouri residents.

For information about accessibility or to request accommodations, please contact me at 573‑677‑1456 or evette@medicareprecision.com. My Accessibility Statement is available on my Disclaimers page.

Contact Info

Cuba, MO
573-677-1456
evette@medicareprecision.com

Scope of Appointment

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