GET ACELL PHONE

350 MINUTESEVERY MONTH

AND

Please make at least one phone call every month in order to keep your Lifeline benefits. Text messaging is not enough!

With SafeLink Health Solutions® you will get:

HealthKeepers, Inc. is proud to be working with SafeLink Wireless to offer you this special federal program!

A FREE phone and 350 monthly minutesUNLIMITED text messagesFREE CALLS to Anthem HealthKeepers Plus Member Services that will not count towards your 350 minutesText messages with HEALTH TIPS and REMINDERS

There are no bills so there are no surprises. If you run out of minutes, you can buy extra for just $0.10 a minute. You will always be able to call 911 or Anthem HealthKeepers Plus Member Services for free, even if you run out of minutes.

3 ways to enroll in Your Healthcare Provider Phone Program:

1. Visit www.safelink.com to apply online.

2. Fill out the application and mail it back (no postage necessary).

3. Call SafeLink at 1-877-631-2550.

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For questions please call 1-877-631-2550

Mail application to: SafeLink Wireless® w PO Box 220009 w Milwaukie, OR 97269-0009Fax application to: 1-866-902-5756 Promo Code:

To get your phone faster apply at www.safelink.com

and enter the promo code above where requested

Only a parent’s or guardian’s personal information

should be used to complete this application.

*

Last Name

First Name

MI

Please fill in the sections below if you are 18 years or older or applying on behalf of your child.

*Contact Phone Number

Last four Digits of Social Security #*

*

Select if address is temporary: o

Member Name ____________________________________________________________________________

Applicant Signature Date

SECTION

3 You MUST check off (a) all statements, then Sign and Date application. (Your application cannot be approved without these items.)

3easy

steps3easy

steps3easy

steps

Your Birth Date (Month/Day/Year)*

Boxe

s M

UST

be

chec

ked

off

ENROLL TODAY & GET:

After 4 months the program returns to the

original plan of 250 minutes.

Free Minutes for

the First 4 Months!*

500*For a limited time only!

NEWCustomers

Monthly

minutes 250 250

MonMontnthh yy

ttesesssnth yh yMontMontnthhlyhlyhlyly yyyy

252525252550505050502250

Plan Features

Choose your plan (check one)

Local Calls

National Long Distance

Voice Mail

Roaming at no Additional Cost

Free 911

411 Directory Assistance at no Additional Cost

Carry-Over Minutes from Month to Month

**

100+ International Long Distance Destinations*

•Exclusive Features for Anthem Members

200 Bonus Minutes

Nationwide Text Messages

Free Outbound Calls to Member Services

Interactive, Daily Health Alert Messages

* List of destinations available at www.safelink.com

** If you choose this plan, your unused minutes will be removed/wiped out and will not carry-over on your next monthly minutes delivery.

However, if you purchase and redeem additional minutes cards, all unused minutes will carry over for three consecutive months.

and expenses.

HEALTH TEXT MESSAGING SERVICES

By signing below I understand that I will be automatically subscribed to FREE health tips and reminders that will be sent to me by text message using information provided by

WellPoint. I authorize

will be used in accordance with the Privacy Policy found at www.voxiva.com/terms. I understand that this authorization is voluntary and if I refuse to grant this authorization

I agree that WellPoint/Anthem/An approved party may call or text me on this phone. I understand that with this service:

• Calls I get could be automated • Coverage area may be limited • Phone models are limited

I certify under penalty of perjury to each of the following:

I, or a member of my household, participate in the above designated qualifying program.

I understand that I must notify SafeLink® within 30 days if I no longer participate in the qualifying program, if I or another member of my

household obtains Lifeline supported service from another carrier, or if I no longer qualify for Lifeline support.

I understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in termination of my

If I change my address, I will provide my new address to SafeLink® within 30 days.

The information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that providing false or

(2) access any records required to verify my statements herein; (3) update my address to a proper mailing address format; (4) provide my name, telephone number and address to the Universal Service

o

I understand that my household may receive only one Lifeline supported service. My Household does not currently receive Lifeline Service

OR

Anthem will confirm your eligibility.

I hereby certify that I participate in the following public assistance program:

Enter full name of the Anthem member (REQUIRED)

For questions please call 1-877-631-2550

Mail application to: SafeLink Wireless® w PO Box 220009 w Milwaukie, OR 97269-0009Fax application to: 1-866-902-5756 Promo Code:

To get your phone faster apply at www.safelink.com and enter the promo

code above where requested

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association.

® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield.

This offer is for families with an Anthem® Blue Cross Blue Shield member. You must be 18 or older to fill out this application. Use the information of a parent or guardian for sections 1 and 3.

Do not use your child’s information. If you do, your application will be rejected. Please provide ONLY VALID personal information for ALL (*) REQUIRED FIELDS. It will be validated against public

records, and any discrepancies will result in REJECTION of your application.

Serving Hoosier Healthwise and Healthy Indiana Plan

FULL CERTIFICATION APPLICATION FOR INDIANA LIFELINE ASSISTANCE PROGRAM

For Spanish: 888-230-0790

o Medicaid (Not the Same as Medicare) o Supplemental Security Income (SSI) o Temporary Assistance for Needy Families (TANF)

Enroll Today& Get Exclusive Benefits:

200One-time

bonusminutes

100Minuteson yourbirthday

HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

NewSafeLinkMedicaidFlyer_V07_WLPT_VA.indd 1 8/4/2015 4:01:05 PM

Por favor, haga al menos una llamada telefónica cada mes con el fin de mantener los beneficios de Lifeline. ¡No basta con enviar un mensaje de texto!

RECIBA UNCELULAR

350 MINUTOSCADA MES

Y

Con las Soluciones de Salud de SafeLink® usted obtendrá:UN CELULAR GRATUITO y 350 minutos cada mesMENSAJES DE TEXTO ILIMITADOSLLAMADAS GRATIS al Servicio al cliente de Anthem HealthKeepers Plus que no serán descontadas de sus 350 minutos.Mensajes de Texto con CONSEJOS DE SALUD y RECORDATORIOS

No hay facturas, así que no hay sorpresas. Si se le acaban los minutos, puede comprar más por solo $0.10 por minuto. Usted siempre tendrá la oportunidad de llamar al 911 o los servicios al cliente de Anthem HealthKeepers Plus de forma gratuita, incluso si se le acaban los minutos.

3 maneras de inscribirse en el programa telefónico de SafeLink y su Programa de Salud:

1. Visite www.safelink.com para solicitar la inscripción en línea.

2. Complete una solicitud y envíela de regreso por correo usando el sobre adjunto [no requiere estampilla).

3. Llame a SafeLink al 1-877-631-2550 para completar una solicitud por teléfono.

¡HealthKeepers, Inc. está orgulloso de trabajar con SafeLink Wireless para ofrecerle este programa federal especial!

1207667

Suscríbase Hoy y Obtenga Los SiguientesBeneficios Exclusivos:

Un bonoúnico de

200minutos

adicionales

100Minutos

extra en elmes de su

cumpleaños

SECTION

1

W

LP

T

SECTION

2

For questions please call 1-877-631-2550

Mail application to: SafeLink Wireless® w PO Box 220009 w Milwaukie, OR 97269-0009Fax application to: 1-866-902-5756 Promo Code:

To get your phone faster apply at www.safelink.com

and enter the promo code above where requested

Only a parent’s or guardian’s personal information

should be used to complete this application.

*

Last Name

First Name

MI

Please fill in the sections below if you are 18 years or older or applying on behalf of your child.

*Contact Phone Number

Last four Digits of Social Security #*

*

Select if address is temporary: o

Member Name ____________________________________________________________________________

Applicant Signature Date

SECTION

3 You MUST check off (a) all statements, then Sign and Date application. (Your application cannot be approved without these items.)

3easy

steps3easy

steps3easy

steps

Your Birth Date (Month/Day/Year)*

Boxe

s M

UST

be

chec

ked

off

ENROLL TODAY & GET:

After 4 months the program returns to the

original plan of 250 minutes.

Free Minutes for

the First 4 Months!*

500*For a limited time only!

NEWCustomers

Monthly

minutes 250 250

MonMontnthh yy

ttesesssnth yh yMontMontnthhlyhlyhlyly yyyy

252525252550505050502250

Plan Features

Choose your plan (check one)

Local Calls

National Long Distance

Voice Mail

Roaming at no Additional Cost

Free 911

411 Directory Assistance at no Additional Cost

Carry-Over Minutes from Month to Month

**

100+ International Long Distance Destinations*

•Exclusive Features for Anthem Members

200 Bonus Minutes

Nationwide Text Messages

Free Outbound Calls to Member Services

Interactive, Daily Health Alert Messages

* List of destinations available at www.safelink.com

** If you choose this plan, your unused minutes will be removed/wiped out and will not carry-over on your next monthly minutes delivery.

However, if you purchase and redeem additional minutes cards, all unused minutes will carry over for three consecutive months.

and expenses.

HEALTH TEXT MESSAGING SERVICES

By signing below I understand that I will be automatically subscribed to FREE health tips and reminders that will be sent to me by text message using information provided by

WellPoint. I authorize

will be used in accordance with the Privacy Policy found at www.voxiva.com/terms. I understand that this authorization is voluntary and if I refuse to grant this authorization

I agree that WellPoint/Anthem/An approved party may call or text me on this phone. I understand that with this service:

• Calls I get could be automated • Coverage area may be limited • Phone models are limited

I certify under penalty of perjury to each of the following:

I, or a member of my household, participate in the above designated qualifying program.

I understand that I must notify SafeLink® within 30 days if I no longer participate in the qualifying program, if I or another member of my

household obtains Lifeline supported service from another carrier, or if I no longer qualify for Lifeline support.

I understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in termination of my

If I change my address, I will provide my new address to SafeLink® within 30 days.

The information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that providing false or

(2) access any records required to verify my statements herein; (3) update my address to a proper mailing address format; (4) provide my name, telephone number and address to the Universal Service

o

I understand that my household may receive only one Lifeline supported service. My Household does not currently receive Lifeline Service

OR

Anthem will confirm your eligibility.

I hereby certify that I participate in the following public assistance program:

Enter full name of the Anthem member (REQUIRED)

For questions please call 1-877-631-2550

Mail application to: SafeLink Wireless® w PO Box 220009 w Milwaukie, OR 97269-0009Fax application to: 1-866-902-5756 Promo Code:

To get your phone faster apply at www.safelink.com and enter the promo

code above where requested

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association.

® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield.

This offer is for families with an Anthem® Blue Cross Blue Shield member. You must be 18 or older to fill out this application. Use the information of a parent or guardian for sections 1 and 3.

Do not use your child’s information. If you do, your application will be rejected. Please provide ONLY VALID personal information for ALL (*) REQUIRED FIELDS. It will be validated against public

records, and any discrepancies will result in REJECTION of your application.

Serving Hoosier Healthwise and Healthy Indiana Plan

FULL CERTIFICATION APPLICATION FOR INDIANA LIFELINE ASSISTANCE PROGRAM

For Spanish: 888-230-0790

o Medicaid (Not the Same as Medicare) o Supplemental Security Income (SSI) o Temporary Assistance for Needy Families (TANF)

HealthKeepers, Inc. es un licenciatario independiente de Blue Cross and Blue Shield Association. ANTHEM es una marca registrada de Anthem Insurance Companies, Inc. Los nombres de Blue Cross and Blue Shield y los símbolos son marcas registradas de Blue Cross and Blue Shield Association.

NewSafeLinkMedicaidFlyer_V07_WLPT_VA.indd 2 8/4/2015 4:01:06 PM