The Centers for Medicare & Medicaid Services (CMS) requires Kansas Health Advantage Representatives to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or his/her authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.
You have my permission to contact me at the phone number below.
By signing this form, you agree to a meeting with an Kansas Health Advantage license sales agent to discuss the Kansas Health Advantage Medicare Advantage/Prescription Drug Benefit Plan. Please note, the person who will discuss the plan is either employed or contracted by Kansas Health Advantage. The person does not work directly for the Federal government. This individual may also be paid based on your enrollment in the plan.
Signing this form does NOT obligate you to enroll in Kansas Health Advantage (HMO I-SNP) or affect your current or future Medicare enrollment status.
Beneficiary or Authorized Representative Signature and Signature Date: