Photo of Caleb Anderson
Your licensed agent
Caleb Anderson
INS Marketing Systems, INC
Phone: 972-223-7979
clctinsurance@gmail.com
ihelpenroll.com
NPN: 18951682
Scope & Consent - Secure SOA & Permission to Contact
Complete the combined PTC and SOA below. After Submit, enter the code sent to your email before your document is submitted to this agent.

Complete your PTC + SOA

One page. Your choices. Your contact and pending form are saved when you request a code. Your signature requires your final confirmation.

Your information

Enter your own information below. This public page never looks up or displays another person's records. Street address, city, state and ZIP stay in their separate fields.

Mailing address
Example: 123 Example Street, Apt 4B. Enter city, state and ZIP below.
5 digits or ZIP+4; leading zeros are kept.

We send a one-time code to the signing person's email after you select Submit my form. Enter the code and select Verify and submit to agent to finish.

Helping someone use a phone or computer does not by itself authorize you to sign for them.

Authorized representative
The confirmation code and private copies go to this signing person.
Use the beneficiary email above, or the representative email when the representative signs.

Information supplied by your agent

Licensed agent
Caleb Anderson
Agency (optional)
INS Marketing Systems, INC
Agent phone
972-223-7979
Agent email
clctinsurance@gmail.com
Individual NPN
18951682
Initial method of contact
Consumer-initiated public agent page
Contact request details
Self-service combined PTC and SOA; email confirmation required
Request recorded
10/27/2026 1:46 PM CDT
Appointment reference
Not provided
Plans represented, as entered by agent
Not provided
Time zone: America/Chicago

Changing the date or format requests a correction for the agent to review; it does not book or reschedule a calendar appointment. Plans listed above do not select your permitted topics below.

The agent identity and recorded contact history stay as entered. Tell the agent about anything else that needs correcting below.

2027

Permission to Contact

This form documents your request and permission for the agency and/or licensed insurance agent identified above to contact you regarding Medicare and Medicare-related health plan information. This form gives permission to contact you only. The specific product categories that may be discussed during a personal Medicare marketing appointment are documented separately on the Scope of Appointment (SOA).

I request and give permission for the agency and/or licensed agent named on this form to contact me about Medicare and Medicare-related health plan information using the contact method(s) I select below. This permission applies only to the agency/agent identified on this form. I may ask not to be contacted at any time.

CMS permits beneficiary-requested or beneficiary-consented contact. Unless you revoke it earlier, this request may be used for follow-up contact for up to 12 months within the purpose of this request. A separate SOA is required before a personal Medicare marketing appointment and controls which health care product categories may be discussed.

CMS contact rule reference: 42 CFR 422.2264(a)(3) / 423.2264(a)(3). This PTC intentionally does not list product categories. Those selections belong on the separate SOA.

2027

Scope of Appointment

The Centers for Medicare & Medicaid Services requires the scope of a personal marketing appointment to be agreed upon and documented before the appointment begins so the beneficiary (or authorized representative) and licensed agent understand which healthcare-related products may be discussed. For an in-person personal marketing appointment, the scope must be documented in writing.

Choose ONE method. Initial ALL PRODUCTS to discuss every listed category, or initial only the individual categories you agree to discuss. Nothing is selected for you.

STAND-ALONE MEDICARE PRESCRIPTION DRUG PLANS (PART D)

Prescription Drug Plans (PDPs) add Part D prescription drug benefits to Original Medicare and certain other Medicare arrangements.

MEDICARE ADVANTAGE PLANS (PART C), COST PLANS AND OTHER MEDICARE HEALTH PLANS

May include HMO, PPO, HMO-POS, PFFS, Special Needs Plans (SNP), Medical Savings Account (MSA), MA-PD, and Medicare Cost Plans, when available.

DENTAL / VISION / HEARING PRODUCTS

Supplemental products that may provide benefits for dental, vision, or hearing services. These products are separate from Medicare.

HOSPITAL INDEMNITY / SUPPLEMENTAL HEALTH PRODUCTS

Supplemental insurance products that may pay fixed or specified benefits based on covered medical services or events. These products are separate from Medicare.

MEDICARE SUPPLEMENT (MEDIGAP) PRODUCTS

Medicare Supplement insurance helps pay certain deductibles, coinsurance, and other gaps in Original Medicare, depending on the policy selected.

By signing this form, you agree to meet with a licensed sales agent to discuss only the product categories you affirmatively selected above. The agent does not work directly for the federal government and may be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll, affect your current or future Medicare enrollment, or automatically enroll you in a Medicare plan.

Sign and submit

Read both sections and enter your signature name once. Drawing is optional. Your signature takes effect after you enter the emailed code and confirm your submission, including on a return visit. You need internet, a supported browser and access to the signing email. Your private link provides a PDF copy to save or print with a PDF viewer.

You may ask your agent for paper forms or a paper copy without a system charge, or withdraw agreement to electronic signing before confirming. This does not undo an already signed record. To correct details after requesting a code, choose Edit my form and verify a new code.

Your signature - enter once

Signing person: . Type this person’s full name once. Drawing is optional.

Used on both documents when PTC is granted.

PTC is signed only when you grant permission. Declining PTC does not stop you from signing the SOA for your selected topics.

Your entries are saved as an unconfirmed contact and pending form for your agent. Your one signature takes effect only after your confirmation. The agent will review your submission and sign their own SOA section.

CY2027 Generic Agency Template - not issued or approved by CMS.

No Medicare number, Social Security number, payment information or medical history is requested. Your entries are stored encrypted as an unconfirmed contact and pending form. The private return link is available for up to eight days from the first code request. Resending does not extend it. Unconfirmed records remain stored pending the separate retention-cleanup update; routine backups may retain prior copies. No consumer account is needed.

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