I provide my signature expressly consenting to contact from Medical Air Servies Association, INC. ("COMPANY") and/or its subsidiaries, affiliates, or agents to contact me regarding products or services via live, automated or prerecorded call, text or email, or regular mail. I understand that I am not required to enter into this consent as a condition of purchase. I can revoke this consent by calling 1-800-643-9023.
For complete list of benefits, premiums, and full terms, conditions and restrictions, please refer to the applicable member services agreement or policy for your state and territory.
THIS AUTHORIZATION REMAINS IN FULL FORCE AND EFFECT AND THIS MEMBERSHIP WILL RENEW AUTOMATICALLY UPON EXPIRATION OF THE MEMBER'S INITIAL MEMBERSHIP TERM FOR A TERM EQUAL TO THE INITIAL MEMBERSHIP TERM UNLESS CANCELLED IN ACCORDANCE WITH THE TERMS AND CONDITIONS OF THIS MEMBERSHIP.

As a convenience to me, I authorize I.B.S. Inc, to charge my account; electronic funds transfers (ACH), debit or credit card transactions or other account debits made upon my account by and payable to the order of I.B.S. its legal representatives for membership, benefits and/or insurance premiums paid on my behalf. I agree that I.B.S. treatment of each ACH or debit, and I.B.S. rights with respect to it, will be the same as if it were signed or initiated personally by me. I further agree that if any ACH or debit is dishonored for any reason, I.B.S. will not be under any liability even though dishonored transactions result in the forfeiture of insurance, benefits, or membership. I further agree that this authorization is to remain in effect until I.B.S. receives written notice from me of its revocation.

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Premium payments will be automatically deducted on the last business day of each month.

Coverage will become effective on the first day of the month following completion of the enrollment form.

Please list all eligible dependents to receive this benefit (if applicable).

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