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pdfSSA Medicare Part B Online Application
Screen Package
April 29, 2020
Page 1|8
MPBOA Screen Package
Contents
Application Landing Page: ...................................................................................................................................................... 3
BOT Handling Page: ................................................................................................................................................................ 4
Enrollment Application: ......................................................................................................................................................... 4
Signature Block: ...................................................................................................................................................................... 5
E-signature and applicant email input:.................................................................................................................................. 5
E-signature confirmation instructions: .................................................................................................................................. 6
E-signature confirmation email: ............................................................................................................................................ 6
E-signature completion messaging: ....................................................................................................................................... 7
E-signature completion email: ............................................................................................................................................... 8
APPENDIX: .............................................................................................................................................................................. 8
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MPBOA Screen Package
Application Landing Page:
Page 3|8
MPBOA Screen Package
BOT Handling Page:
Enrollment Application:
See attached PDF for in
Appendix complete form
language
Page 4|8
MPBOA Screen Package
Signature Block:
E-signature and applicant email input:
Page 5|8
MPBOA Screen Package
E-signature confirmation instructions:
E-signature confirmation email:
Page 6|8
MPBOA Screen Package
E-signature completion messaging:
Page 7|8
MPBOA Screen Package
E-signature completion email:
APPENDIX:
Medicare Part B
WebForm - Final.pdf
Page 8|8
MPBOA Screen Package
| File Type | application/pdf |
| Author | Kao, Christopher Contractor |
| File Modified | 2020-05-06 |
| File Created | 2020-05-06 |