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Get Scope Of Sales Appointment Confirmation Form

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 enrollment or enroll you in Y00711317305R CMS Approved 06/30/2013 822430 38092WLP Non Model Scope of Appointment SH 06 13 38092WLP Beneficiary or Authorized Representative Signature and Signature Date Signature If you are the authorized representative please sign above and print below Representative .

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