Scope of Appointment (SOA) Form
Click here to get the form. Scope of Appointment (SOA) form (pdf)
The completed form can be mailed to:
Ideal Insurance Servicesor it can emailed to SOA@ideal-medicare.com. It may not be faxed, as that cannot guarantee privacy.
The Medicare beneficiary or their authorized representative MUST initial all boxes that apply, and SHOULD print their name in the box with their signature. An authorized representative is a person who would sign on behalf of the Medicare Beneficiary due to Power of Attorney status. If the beneficiary, or the authorized representative, has any questions, they may call Ideal Insurance Services at (248) 320-9824. If there is more than one beneficiary interested in a single appointment, Ideal Insurance Services needs a separate Scope of Appointment (SOA) form for each beneficiary. Please write in your phone number if you would like a phone call.
Steve Chudnow, DBA Ideal Insurance Services, a domestic U.S. insurance agency licensed to do business in Michigan and Florida.
An authorized independent Agent for Blue Cross Blue Shield of Michigan and Blue Care Network.