Compliance Training

Medicare Advantage – Provider Marketing Acknowledgement Form

All providers who contract with SummaCare to provide Medicare Advantage services are expected to abide by the Centers for Medicare & Medicaid Services (CMS) rules for marketing when it involves SummaCare products or benefits. The below guidelines are applicable to providers.

CMS is concerned with provider marketing activities for the following reasons: 

  • Provider may not be fully aware of all plan benefits, rules and costs.
  • Provider may confuse the patient because he/she perceives the provider as acting as an agent of the plan versus acting as the person’s provider.
  • Providers may face conflicting incentives when acting as a plan sponsor representative.

This form must be completed by all contracted providers existing and new that will be displaying or providing marketing materials on behalf of the health plan.

This form will be an acknowledgement that the provider has received educational information from the plan about the Medicare Marketing guidelines and restrictions on provider marketing.

If you are a contracted provider, indicate your business name and tax identification (ID) number below.

Name of contracted provider (if applicable)
Tax ID

Enter your name, title, telephone number, signature, and date that you completed this acknowledgement form:


You have read the Provider Marketing Education sheet and understand that providers must adhere to all applicable laws, regulations and CMS guidelines regarding MA plan marketing, including the Marketing Guidelines found in Chapter 3 of the Medicare Managed Care Manual.


Regulatory Criteria