There is no enrollment at this link. Please verify the web page link and try again.

You cannot enroll outside the enrollment period.

Enrollment Start Date: {{EnrollmentStartDate}}
Enrollment End Date: {{EnrollmentEndDate}}

{{GroupName}} MASA MTS Enrollment Form

Choose your product
{{ product.Title }}

Primary


Spouse

Dependents

Physical Address

Mailing Address(Not required if checkbox above is checked)


Health Plan Coverage
I will be enrolled in an HSA-eligible health plan on my plan effective date.
I will not be enrolled in an HSA-eligible health plan on my plan effective date.
I acknowledge that by clicking above I have elected to enroll into MASA MTS’ plan program. I hereby authorize my employer to deduct from my paycheck(s) an amount equivalent to the selected amount for the corresponding MASA MTS plan. I further acknowledge, that should my employment with my employer be terminated, whether voluntarily or involuntarily, my employer will have the right to deduct from my final paycheck any and all amounts paid upfront by my employer for my MASA MTS plan that have yet to be deducted from my paycheck(s).
I acknowledge that I have been offered the opportunity to enroll in the MASA MTS plan program via a payroll deduction and have decided to opt out. Additionally, I understand the potential out of pocket exposure resulting from an emergent air or ground transport and willingly assume the responsibility of such balance bill.
I authorize Piedmont Payment Services, LLC (PIEDMONT) to perform electronic funds transfer (EFT) debits on a semi-monthly basis from the account shown above, and I authorize my bank to debit the account shown above. I understand that the funds, less the service fee, will be used to pay the BILLER(S) listed above. I also understand that my accounts with the BILLER(S) may be cancelled if any EFT attempt is returned/declined resulting in insufficient funds to pay my invoiced amounts in full. If any EFT debit is returned/declined by my financial institution as unpaid (non-sufficient funds or uncollected funds), I authorize Piedmont to suspend future attempts, and I understand that I will be responsible for future payments to the BILLER(S).
This authorization is to remain in force until PIEDMONT has received notification of its termination. Any termination notice should be sent to PIEDMONT by mail to: PO Box 940, Fortson, Georgia 31808 or by e-mail with reply requested to: support@piedmontpays.com. By signing this document, I acknowledge that I have read and agree with the Processing Terms and Conditions. If not attached here, a complete copy may be found at http://www.piedmontterms.com
I affirm that I have Major Medical Health Insurance through Insurance Company with Plan #. My medical coverage is currently in force, covers emergency transportation situations, and does not contain unreasonable limitations on repayment to providers for emergency transportations. I affirm that the aforementioned coverage will continue to be maintained so long as I am a MASA member, and that the failure to maintain such coverage may render my MASA plan null and void.

{{FraudLanguageText}}
Name
Print PDF