With SafeLink Health Solutions® you will get:

Kaiser Permanente is proud to be working with SafeLink Wireless to offer you this special federal program!

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 Kaiser Permanente Member Services for free, even if you run out of minutes.

3 ways to enroll in the Kaiser Permanente SafeLink Wireless 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.

3easy

steps3easy

steps3easy

steps

FULL CERTIFICATION APPLICATION FOR VIRGINIA LIFELINE ASSISTANCE PROGRAM

SECTION

1

PART 2: ONLY COMPLETE THIS PART IF APPLYING VIA PROGRAM AND YOUR CHILD OR DEPENDENT IS THE

PARTICIPANT OF THE QUALIFYING PROGRAM. (Fields with (*) are mandatory.)

PART 1: APPLICANT PERSONAL INFORMATION. You must be 18 or older to fill out this application. (Fields with (*) are mandatory.)

Applicant Signature Date

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

and enter the promo code above where requested

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

For questions please call 1-877-631-2550

SECTION

2

Boxe

s M

UST

be

chec

ked

off

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

SECTION

3

Lifeline is available for only one line per household. A household is defined as any individual or group of individuals who live together at the

same address and share income and expenses. A household is not permitted to receive Lifeline benefits from multiple providers. Violation of

the one-per-household rule constitutes a violation of FCC rules and will result in the Customer’s disenrollment from Lifeline. Lifeline is a non-

transferable benefit, and a Customer may not transfer his or her benefit to another person.

o Check this box if you would like to receive pre-recorded special offers and promotional offers from TracFone at the Contact Telephone number provided above.SafeLink® is a Lifeline supported service. Lifeline is a federal benefit, and only eligible subscribers may enroll. Customers who willfully make false statements

in order to obtain the benefit can be punished by fine or imprisonment or can be barred from the program.

By signing below, I certify under penalty of perjury to each of the following:

I, or a dependent in 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, for any other reason, 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 Lifeline benefits.

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

Service OR my household currently receives Lifeline Service from another carrier and I authorize SafeLink to transfer my Lifeline benefit

to SafeLink and I understand this will terminate my Lifeline benefits with my existing carrier. 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 fraudulent information to obtain Lifeline benefits is punishable by law.

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

Kaiser Permanente will confirm your eligibility.

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

Mailing Address if different from your Qualifying Home Address (P.O. Box Allowed)

StateZIP code

City

Address/Apt. No.

Please make sure to complete Section 1 (Part 1) and section 3 with the parent or guardian information.*Child or Dependent Birth Date (MM/DD/YYYY)

*Child or Dependent last four Digits of Social Security #

*Child or Dependent Last Name

*Child or Dependent First Name

MI

*Birth Date (Month/Day/Year)

* Last Four Digits of Social Security #

Contact Phone NumberMI

*Legal Last Name

*Legal First Name

Confirm applicant’s name & home address, provide mailing address if different and complete mandatory personal information below.

A household is eligible for Lifeline, if any member is a “qualified participant” of any program listed below or if the total household income is at or below the

guidelines in Section 2.

• Qualified participant – Complete : Section 1 (Part 1, only), Section 2 and Section 3

• To apply using a child or dependent in your household as “qualified participant” – Complete : Section 1 (Part 1, and Part 2), Section 2 and Section 3

Qualifying Home Address (No P.O. Box)

Select if address is temporary:

A

MH

C

SafeLink

Smartphone

Receive 500MB of FREE

data every month.

Bring-Your-

Own-Phone (BYOP)*

Receive 1GB of FREE Data

for the first 3 months,

500MB thereafter.OR

*You must have a T-Mobile or Unlocked GSM compatible phone for the BYOP plan.

Select Only One Plan/Phone Option

I am authorizing SafeLink Wireless or its duly appointed representative to (1) Obtain and use information from my healthcare provider to confirm my initial and

ongoing eligibility for Lifeline assistance; (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 Administrative Company (USAC) (the administrator of the program) and its agents

for the purpose of verifying that I do not receive more than one Lifeline benefit; (5) authorize social service agency representatives to discuss with and/or provide

information to SafeLink Wireless® verifying my participation in benefit programs that qualify me for Lifeline assistance; and (6) provide enrollment information,

including my new phone number, to Kaiser Permanente and anyone acting on Kaiser Permanente behalf and consent to calls or text messages being sent to that

number that provide information regarding your health plan or health-related issues (including nutritional, medical and healthcare information and reminders).

SafeLink service is offered pursuant to SafeLink Terms and Conditions, which can be found at www.safelink.com

1222480.indd 1

10/4/2016 8:11:01 AM

A FREE phone and 350 monthly minutesUNLIMITED text messagesMOBILE DATA (Varies by plan)FREE CALLS to Kaiser Permanente Member Services that will not count towards your 350 minutesText messages with HEALTH TIPS and REMINDERS

Plan Features

Exclusive Features for Healthcare Members

SafeLinkSmartphone

SafeLink BYOP

• Free Outbound Calls to Member Services• Interactive Daily Health Alert Messages

AT&TT-MobileGSM Unlocked

SafeLink BYOP Carrier Selection*(Select one option)

Select Plan/Phone Options

Bring-Your-Own-Phone (BYOP)

Receive 1GB of datafor the �rst 3 months,500MB thereafter.

SafeLinkSmartphone

Receive 500MB ofdata every month.

BRING YOUR OWN PHONETODAY & GET:

1GBof data for

the first 3 months!500MB of data thereafter

Please make at least one phone call or send one text message every month in order to keep your Lifeline benefits.

GET ASMARTPHONE,MINUTES,

EVERY MONTH

AND DATA

1222479.indd 1 10/17/2016 10:59:49 AM

Con las Soluciones de Salud de SafeLink® usted obtendrá:

1222479

¡Kaiser Permanente está orgulloso de trabajar con SafeLink Wireless para ofrecerle este programa federal especial!

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 Kaiser Permanente de forma gratuita, incluso si se le acaban los minutos.

3 maneras de inscribirse en el programa inalámbrico SafeLink deKaiser Permanente:

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.

UN CELULAR GRATUITO y 350 minutos cada mesMENSAJES DE TEXTO ILIMITADOSDATOS MOVILES (Varía según el plan)LLAMADAS GRATIS al Servicio al cliente de Kaiser Permanente que no serán descontadas de sus 350 minutos.Mensajes de Texto con CONSEJOS DE SALUD y RECORDATORIOS

Por favor, haga al menos una llamada telefónica o enviar un mensaje de texto cada mes con el fin de mantener los beneficios de Lifeline.

3easy

steps3easy

steps3easy

steps

FULL CERTIFICATION APPLICATION FOR VIRGINIA LIFELINE ASSISTANCE PROGRAM

SECTION

1

PART 2: ONLY COMPLETE THIS PART IF APPLYING VIA PROGRAM AND YOUR CHILD OR DEPENDENT IS THE

PARTICIPANT OF THE QUALIFYING PROGRAM. (Fields with (*) are mandatory.)

PART 1: APPLICANT PERSONAL INFORMATION. You must be 18 or older to fill out this application. (Fields with (*) are mandatory.)

Applicant Signature Date

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

and enter the promo code above where requested

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

For questions please call 1-877-631-2550

SECTION

2

Boxe

s M

UST

be

chec

ked

off

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

SECTION

3

Lifeline is available for only one line per household. A household is defined as any individual or group of individuals who live together at the

same address and share income and expenses. A household is not permitted to receive Lifeline benefits from multiple providers. Violation of

the one-per-household rule constitutes a violation of FCC rules and will result in the Customer’s disenrollment from Lifeline. Lifeline is a non-

transferable benefit, and a Customer may not transfer his or her benefit to another person.

o Check this box if you would like to receive pre-recorded special offers and promotional offers from TracFone at the Contact Telephone number provided above.SafeLink® is a Lifeline supported service. Lifeline is a federal benefit, and only eligible subscribers may enroll. Customers who willfully make false statements

in order to obtain the benefit can be punished by fine or imprisonment or can be barred from the program.

By signing below, I certify under penalty of perjury to each of the following:

I, or a dependent in 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, for any other reason, 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 Lifeline benefits.

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

Service OR my household currently receives Lifeline Service from another carrier and I authorize SafeLink to transfer my Lifeline benefit

to SafeLink and I understand this will terminate my Lifeline benefits with my existing carrier. 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 fraudulent information to obtain Lifeline benefits is punishable by law.

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

Kaiser Permanente will confirm your eligibility.

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

Mailing Address if different from your Qualifying Home Address (P.O. Box Allowed)

StateZIP code

City

Address/Apt. No.

Please make sure to complete Section 1 (Part 1) and section 3 with the parent or guardian information.*Child or Dependent Birth Date (MM/DD/YYYY)

*Child or Dependent last four Digits of Social Security #

*Child or Dependent Last Name

*Child or Dependent First Name

MI

*Birth Date (Month/Day/Year)

* Last Four Digits of Social Security #

Contact Phone NumberMI

*Legal Last Name

*Legal First Name

Confirm applicant’s name & home address, provide mailing address if different and complete mandatory personal information below.

A household is eligible for Lifeline, if any member is a “qualified participant” of any program listed below or if the total household income is at or below the

guidelines in Section 2.

• Qualified participant – Complete : Section 1 (Part 1, only), Section 2 and Section 3

• To apply using a child or dependent in your household as “qualified participant” – Complete : Section 1 (Part 1, and Part 2), Section 2 and Section 3

Qualifying Home Address (No P.O. Box)

Select if address is temporary:

A

MH

C

SafeLink

Smartphone

Receive 500MB of FREE

data every month.

Bring-Your-

Own-Phone (BYOP)*

Receive 1GB of FREE Data

for the first 3 months,

500MB thereafter.OR

*You must have a T-Mobile or Unlocked GSM compatible phone for the BYOP plan.

Select Only One Plan/Phone Option

I am authorizing SafeLink Wireless or its duly appointed representative to (1) Obtain and use information from my healthcare provider to confirm my initial and

ongoing eligibility for Lifeline assistance; (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 Administrative Company (USAC) (the administrator of the program) and its agents

for the purpose of verifying that I do not receive more than one Lifeline benefit; (5) authorize social service agency representatives to discuss with and/or provide

information to SafeLink Wireless® verifying my participation in benefit programs that qualify me for Lifeline assistance; and (6) provide enrollment information,

including my new phone number, to Kaiser Permanente and anyone acting on Kaiser Permanente behalf and consent to calls or text messages being sent to that

number that provide information regarding your health plan or health-related issues (including nutritional, medical and healthcare information and reminders).

SafeLink service is offered pursuant to SafeLink Terms and Conditions, which can be found at www.safelink.com

1222480.indd 1

10/4/2016 8:11:01 AM

RECIBA UNSMARTPHONE,MINUTOS

CADA MES

Y DATOS

Plan Features

Exclusive Features for Healthcare Members

SafeLinkSmartphone

SafeLink BYOP

• Free Outbound Calls to Member Services• Interactive Daily Health Alert Messages

AT&TT-MobileGSM Unlocked

SafeLink BYOP Carrier Selection*(Select one option)

Select Plan/Phone Options

Bring-Your-Own-Phone (BYOP)

Receive 1GB of datafor the first 3 months,500MB thereafter.

SafeLinkSmartphone

Receive 500MB ofdata every month.

TRAIGA SU PROPIO TELÉFONO HOY MISMO Y RECIBA:

1GBde datos durante

los primeros 3 meses500MB de datos en

los siguientes meses

1222479.indd 2 10/17/2016 10:59:51 AM