Medical Air Services Association (MASA) Membership Application

At MASA we take pride in the fact that in our long history we have never increased an annual member’s rates regardless of
how many times they have used MASA’s services or how long they are MASA members. Members who joined many years
ago are still paying the rate in effect at the time that they joined.
Rates and services describe herein are subject to change PRIOR TO enrollment.
Must be age 74 or under

Age 50 and up 1 Year 5 Years

If you, or one of you if a couple, are age 50 & up Save 20%
Family ................................................................... $720 ............................... $2880

Single .................................................................... $540 ............................... $2160

Under age 50 1 Year 5 Years

If you, or both of you if a couple, are under age 50 Save 20%

Family ................................................................... $390 ............................... $1560

Single .................................................................... $290 ............................... $1160

At times MASA offers a Lifetime option, on a very limited basis for new enrollments, for those age 50 and up.
If you have heard about and are interested on our Lifetime option contact us and tell us where you heard about it.

Total from above __________

+ $60
One time application fee __________
Total enclosed __________

Name ________________________________________________ Spouse/________________________________________________

Last First M. I. Partner Last First M. I.
Birth date _____/_____/________ Social (last 4)_________ Birth date _____/_____/________ Social (last 4)_________

Address______________________________________________City_________________________State___________Zip___________
Phone _______________________________ Cell ___________________________ Email ____________________________________
If applicable list your dependent children living at home up to age 18 or age 23 if attending college. Use separate piece of paper if needed.
Name:___________________________ D.O.B.___/___/_______ Name:___________________________ D.O.B.___/___/_______
Name:___________________________ D.O.B.___/___/_______ Name:___________________________ D.O.B.___/___/_______
Name:___________________________ D.O.B.___/___/_______ Name:___________________________ D.O.B.___/___/_______

Payment enclosed: Check Money Order Credit Card Number:__________________________________________ Exp Date__________

Signature:__________________________________________________________________________ Date:______________________
Where did you hear about MASA? Referred by, attended MASA meeting at, MASA rep name, etc._______________________________________________________________

Pre-existing conditions are covered after 90 days. You should receive your membership package in 10 to 14 days including your Member Services
Agreement, temporary cards to carry with you, a receipt, and window stickers for your vehicles and home. You will receive your permanent cards in 4
to 6 weeks. Your MASA membership is effective immediately upon receipt by MASA. Due to the way MASA processes new applications it may be 2
to 3 weeks before your account is charged.

Make checks payable to: Mail your application to:

For additional information call:
Medical Air Services Association MASA 1-800-809-5745
P.O. Box 1288
or MASA Veradale, WA 99037