WITH SAFELINK HEALTH SOLUTIONS®,YOU WILL GET:

APPLY TODAY! Select the KEEP YOUR OWN SMARTPHONE** program

• A SMARTPHONE,1GB of data and 350 monthly minutes**

Visit SafeLink.com to apply online

Fill out the application in this envelope and mail it back (no postage necessary)

Call SafeLink at 1-877-631-2550

• UNLIMITED text messages

• Text messages with HEALTH TIPS and REMINDERS

There are no bills so there are no surprises!

* To Keep Your Own Smartphone, you must have a compatible GSM phone (which includes T-Mobile andAT&T compatible phones). Your phone must also be unlocked. Several other carriers also use GSM networks.To confirm yours is included, call your carrier.**Unused minutes and data will not Carryover from month-to-month. A month equals 30 days.

ALREADY HAVE YOUR OWN PHONE?

Please make at least one phone call or send a text message each month in order to keep your Lifeline benefits.Si desea información en Español visite www.SafeLink.com para llenar la inscripción

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

• FREE CALLS to MOLINA Member Services that will not count towards your 350 minutes

MOLINA is proud to be working with SAFELINK WIRELESS to offer members this special federal Lifeline program at no cost to you!

THERE ARE 3 WAYS TO ENROLL INTO THE MOLINA SAFELINK PHONE PROGRAM TODAY:

Jane Q Sample9304 SE Main StMilwaukie, OR 97222-7338

78789294329071234023737212323

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Telephone number provided above.

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

*To Keep Your Own Smartphone, you must have a compatible GSM phone(which includes T-Mobile and AT&T compatible phones).Your phone must also be unlocked.Several other carriers also use GSM networks. To con�rm yours is included, call your carrier.**Unused data will not Carryover from month-to-month. A Month equals 30 Days.

ORReceive 350 minutes and1GB of FREE data everymonth.**

Receive 350 minutes and1.5GB of FREE data for the�rst 3 months, 1GBthereafter.**

Keep-Your-Own-Smartphone* SafeLink Smartphone

Select Only One Plan/Phone Option

I consent to provide enrollment information, including my new phone number, to Molina and anyone acting on Molina’s behalf and consent to calls or text messages generated by automated technology being sent to that number that provide information regarding your health plan or health-related issues (including nutritional, medical and healthcare information and reminders). Consent to these messages is not a requirement to enroll in the SafeLink program. If you do not want to consent to such calls, you may enroll by calling our customer service department at 1-800-Safelink (723-3546).

Molina will confirm your eligibility.

1256391

(By providing your Social Security number we can attempt to validate your Medicaid eligibility electronically) - -

Medicaid(Not the Same as Medicare) (Please provide your 9 Digit Social Security number)

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