MAHSPA2018 Promo Code__________________

with SAFELINK WIRELESS to offer members this special federal LifeLine program MAGELLAN BEHAVIORAL HEALTH OF PENNSYLVANIA INC is proud to be working

at no cost to you

WITH SAFELINK HEALTH SOLUTIONSreg YOU WILL GET bull A SMARTPHONE1GB of data and 1000 monthly minutes

bull UNLIMITED text messages

bull FREE CALLS to MAGELLAN BEHAVIORAL HEALTH OF PENNSYLVANIA INC Member Services will not

count towards your 1000 minutes

bull Text messages with HEALTH TIPS and REMINDERS

There are no bills so there are no surprises

ALREADY HAVE YOUR OWN PHONE APPLY TODAY Select the KEEP YOUR OWN SMARTPHONE program THERE ARE 3 WAYS TO ENROLL INTO THE MAGELLAN BEHAVIORAL HEALTH OF PENNSYLVANIA INC SAFELINK PHONE PROGRAM TODAY

Visit SafeLinkcom to apply online

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

Call SafeLink at 1-877-631-2550

Please make at least one phone call or send a text message each month in order to keep your Lifeline benefits Si desea informacioacuten en Espantildeol visite wwwSafeLinkcom para llenar la inscripcioacuten

en liacutenea o Llame a SafeLink al 1-877-631-2550 para completar una solicitud por teleacutefono To Keep Your Own Smartphone you must have a compatible GSM phone (which includes TshyMobile andATampT compatible phones) Your phone must also be unlocked Several other carriers also use GSM networksTo confirm yours is included call your carrierUnused minutes and data will not Carryover from monthshytoshymonth A month equals 30 days

PLEASE COMPLETE AND RETURN ALL PAPERS IN THE MAILER ENVELOPE

2019 MAHCindd 1 12102018 92252 AM

Select Only One PlanPhone Option Keep-Your-Own-Smartphone SafeLink Smartphone

Receive 1000 minutes and Receive 1000 minutes and 15GB of FREE data for the OR 1GB of FREE data first 3 months every month1GB thereafter

To Keep Your Own Smartphone you must have a compatible GSM phone(which includes T-Mobile and ATampT compatible phones)Your phone must also be unlockedSeveral other carriers also use GSM networks To confirm yours is included call your carrierUnused data will not Carryover from month-to-month A Month equals 30 Days

I consent to provide enrollment information including my new phone number to Magellan Behavioral Health of Pennsylvania Inc and anyone acting on Magellan Behavioral Health of Pennsylvania Incrsquos 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)

Magellan Behavioral Health of Pennsylvania Inc will confirm your eligibility I hereby certify that I participate in the following public assistance program

PMedicaid (Please provide your 9 Digit Social Security number) - -

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

Telephone number provided above

By submitting this application you authorize social service agency representatives to discuss with andor provide information to SafeLink Wirelessreg verifying your participation in benefit programs that qualify you for Lifeline assistance You have the right to revoke this authorization Social service agencies will not condition treatment payment enrollment or eligibility for benefits on your signing of this authorization

PLEASE COMPLETE AND RETURN ALL PAPERS IN THE MAILER ENVELOPE

2019 MAHCindd 2 12102018 92254 AM

1233672