Current iClaim Electronic Signature Agreement Screen

Electronic Signature Agreement (with Special Enrollment Period (SEP)
Medicare Form)
This screen appears at the bottom of the Overall Summary for Benefit Application screen. First
party applicants review the information and checks the box “I agree with the Electronic
Signature Agreement above.” We updated this screen to ensure individuals are clearly informed
that as part of this online submission, they are completing more than one form and providing one
signature for both a Social Security benefit application and the Centers for Medicare and
Medicaid Services (CMS-10797) form.

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