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Appintment Confirmation





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: ___________________________________________________


email Jim your confirmation of receipt of this page:


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Jackie and Jim Spahr
call or fax toll free:
1.800.237.0107 fax  1.888.356.5956
Jackie Spahr  Jim Spahr