Dokimos East Main Pharmacy

640 East Main St #2

Grass Valley, CA

(530) 557-3544

Scope of Appointment Confirmation Form

Medicare requires Licensed Sales Representatives to document the scope of an appointment prior to any sales meeting to ensure understanding of what will be discussed between them and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential. A separate form should be completed for each Medicare beneficiary.

Beneficiary Information

To ensure your appointment with a licensed sales representative focuses on the Medicare and health-related products that are important to you, please select the option(s) that best reflect your interest. *

(Part C) Medicare Advantage Plans

(Part D) Stand Alone Medicare Prescription Drug Plan

Dental, Vision, or Hearing Plans

Supplemental Hospital Plans

(Medi-Gap) Medicare Supplemental Plans

First Name *

Last Name *

Birthdate *

Medicare Beneficiary Identifier

Phone *

Email *

Address *

City *

State *

Postal code *

Legal Representative's Information, if other than Beneficiary.

Authorization for the Use and Disclosure of Protected Health Information: I authorize the pharmacy to securely transmit my protected health information (PHI) to the enrollment platform for the exclusive purpose of Medicare plan enrollment. This information will be used by HPRx Insurance and its affiliates in accordance with HIPAA regulations and CMS guidelines. This authorization does not obligate me to purchase a plan or automatically enroll me in any plan. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. *

Yes

Medicare Beneficiary (applicant) Signature. Please sign below using your finger, a stylus or a mouse. *

Clear

By signing this form, you agree to a meeting with a Licensed Sales Representative to discuss the types of products you checked above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current or future Medicare enrollment, or enroll you in a Medicare plan. I agree to terms & conditions provided. By providing my phone number, I agree to receive text messages, calls and emails from Dokimos East Main Pharmacy pertaining to marketing, as well as, policy information. I understand that my information will never be sold and will be kept in a HIPAA compliant.

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription

drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private

Fee-For-Service Plans, and Medicare Medical Savings Account Plans.

Medicare Advantage Plans (Part C) and Cost Plans

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). Medicare HMO Point-of-Service (HMO-POS) Plans — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. HMO-POS plans may allow you to get some services out of network for a higher copayment or coinsurance.

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that

provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors, providers and hospitals but you can also use out-of-network providers, usually at a higher cost. Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan’s payment,

terms and conditions and agrees to treat you — not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers. Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If

you get services outside of the plan’s network, your Medicare-covered services will be paid for under

Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Other Related Products

Dental/Vision/Hearing Products — Plans offering additional benefits for consumers who are looking

to cover needs for dental, vision, or hearing. These plans are not affiliated or connected to Medicare.

Hospital Indemnity Products — Plans offering additional benefits; payable to consumers based

upon their medical utilization; sometimes used to defray co-pays/co-insurance. These plans are

not affiliated or connected to Medicare.

Medicare Supplement (Medigap) Products — Insurance plans that help pay some of the

out-of-pocket costs not paid by Original Medicare (Parts A and B) such as deductibles and

co-insurance amounts for Medicare approved services

AGENT INFO ONLY

Agent Writing Number

Agent Signature