Medicare & ACA Forms | Kryder Cares, Perrysburg OH

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Consumer authorization & intake forms

Scope of Appointment

Medicare Scope of Appointment form — sign it electronically before we discuss Medicare Advantage or Part D plans.

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Medicare Intake

Medicare intake form — your doctors, prescriptions and coverage goals.

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Marketplace Intake

ACA Marketplace intake form for individual and family health coverage.

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Marketplace Authorization

ACA Marketplace consumer authorization form.

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RetireFlo SOA

Prefer RetireFlo? Complete your Scope of Appointment through Kris’s RetireFlo page.

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Download Forms

Choose the form you need below.

Scope of Appointment: Download Medicare Scope of Appointment form.
Medicare Intake: Download Medicare intake form.
Marketplace Intake: Download ACA Marketplace intake form.
Marketplace Authorization: Download ACA Marketplace authorization form.

What Is a Scope of Appointment?

CMS requires a Scope of Appointment before discussing Medicare Advantage or Part D plans. The form lists the types of products you want to talk about, such as Medicare Advantage or Part D. It protects you by keeping the conversation to the topics you chose.

Signing a Scope of Appointment does not enroll you in anything and does not obligate you to buy a plan. You can complete it online through RetireFlo or download, sign and return the PDF.

Intake and Authorization Forms

The Medicare intake and Marketplace intake forms collect basic details, like your doctors, prescriptions and household information, so Kris can prepare before you meet. The Marketplace authorization form documents your consent for Kris to help with your ACA Marketplace application, which federal Marketplace rules require.

Return completed forms by email to kris@krydercares.com, bring them to the Perrysburg office, or mail them to 842 W South Boundary St, Perrysburg, OH 43551. Questions? Visit the contact page.

FAQ

Frequently asked questions

Why do I need to sign a Scope of Appointment?

CMS requires a Scope of Appointment before discussing Medicare Advantage or Part D plans. It records which types of products you agreed to talk about, so the conversation stays focused on what you asked for. Signing it does not enroll you in a plan, and you are under no obligation to buy anything.

Does signing a Scope of Appointment enroll me in a plan?

No. A Scope of Appointment only documents the topics you want to discuss. It is not an application and does not commit you to anything. You can still choose to enroll in a plan, keep your current coverage, or take more time to think after your meeting with Kris.

Can I complete the Scope of Appointment online?

Yes. You can complete the Scope of Appointment online through RetireFlo, which Kryder Cares uses for electronic forms. You can also download the PDF from this page, sign it and return it by email, by mail, or in person at the Perrysburg office. Either way works.

What information does the Medicare intake form ask for?

The Medicare intake form asks for basics like your name, date of birth, Medicare effective dates, current coverage, doctors and prescriptions. This lets Kris check networks and drug coverage before your appointment. Bring your Medicare card to the meeting too. If you only need a drug comparison, use the Rx drug lookup form.

What is the ACA Marketplace authorization form?

The Marketplace authorization form documents your consent for Kris to help you with your HealthCare.gov application and plan enrollment. Federal Marketplace rules require agents to have your consent before assisting. The form confirms that you want Kris’s help and that the information you provide is accurate as far as you know.

How do I return completed forms?

You can email completed forms to kris@krydercares.com, mail them to 842 W South Boundary St, Perrysburg, OH 43551, or drop them off at the office Monday through Friday, 9:00 AM to 5:00 PM. If you have trouble printing or signing a form, call (419) 277-8097 and Kris can help.