IMPORTANT NOTICE AND APPLICANT ACKNOWLEDGMENT

By submitting this application and/or accepting an ISGH Health Access Card (“Card”), Applicant acknowledges and agrees to the following terms and conditions:

ISGH IS NOT A MEDICAL PROVIDER

The Islamic Society of Greater Houston, Inc. (“ISGH”) is a Texas nonprofit religious and charitable organization and is not a hospital, physician group, clinic, pharmacy, healthcare provider, insurer, health maintenance organization (HMO), medical practice, or healthcare facility.

ISGH does not practice medicine, provide medical diagnoses, prescribe medications, render medical advice, supervise medical treatment, or control the medical judgment of any physician or healthcare provider.

INDEPENDENT MEDICAL PROVIDERS

All healthcare services are provided solely by independent third-party medical providers, clinics, physicians, laboratories, pharmacies, or other healthcare professionals participating in the program (“Participating Providers”).

Participating Providers are not employees, agents, joint venturers, or representatives of ISGH. ISGH does not supervise, direct, control, endorse, or guarantee the medical care, treatment decisions, billing practices, quality of services, availability of services, or professional conduct of any Participating Provider.

NO HEALTH INSURANCE

The ISGH Health Access Card is not insurance and is not intended to replace health insurance coverage.

The Card:

• is not a health insurance policy;
• does not constitute an HMO or managed care plan;
• does not guarantee payment for medical services;
• does not guarantee reimbursement of medical expenses;
• does not create a contractual or any other obligation by ISGH to pay medical bills; and
• does not guarantee eligibility for any specific medical service, treatment, medication, discount, or provider participation.

Applicants are encouraged to maintain independent health insurance coverage whenever possible.

NO GUARANTEE OF SERVICES OR DISCOUNTS

Use of the Card does not guarantee:

• acceptance by any provider;
• continued participation by any provider;
• free medical treatment;
• reduced pricing;
• appointment availability;
• emergency care;
• specialist care; or
• any particular healthcare outcome.

Any reduced-cost or charitable services are determined solely by the Participating Provider in its independent discretion.

APPLICANT REMAINS RESPONSIBLE FOR MEDICAL BILLS

Applicant understands and agrees that Applicant remains solely responsible for all medical bills, co-payments, deductibles, prescription costs, laboratory fees, imaging charges, hospital charges, and all other healthcare-related expenses incurred from any provider.

ISGH is not financially responsible or liable for:

• unpaid medical bills;
• denied services;
• provider billing disputes;
• collections activity;
• malpractice claims;
• treatment outcomes; or
• emergency medical expenses.

NO EMERGENCY SERVICES

The Card is not intended for emergency medical situations.

In the event of a medical emergency, Applicant should immediately call 911 or proceed to the nearest emergency room.

LIMITED CHARITABLE ASSISTANCE PROGRAM

The ISGH Health Access Card Program is a charitable community assistance initiative intended to help individuals with limited financial means identify Participating Providers who may voluntarily offer certain services at reduced cost or without charge.

ISGH reserves the right to approve, deny, suspend, revoke, or discontinue participation in the program at any time and for any lawful reason.

NO WARRANTY OR REPRESENTATION

ISGH makes no representation or warranty, express or implied, regarding:

• the quality, safety, legality, effectiveness, or availability of medical services;
• the qualifications or competency of Participating Providers;
• the accuracy of diagnoses or treatment recommendations; or
• the availability of free or reduced-cost care.

All medical decisions are solely between Applicant and the healthcare provider.

RELEASE AND HOLD HARMLESS

To the fullest extent permitted by Texas law, Applicant releases and agrees to hold harmless ISGH, its mosques, affiliates, directors, officers, officials, volunteers, employees, donors, and representatives from and against any and all claims, liabilities, damages, losses, injuries, costs, or expenses arising out of or related to:

• medical treatment or failure to treat;
• healthcare provider negligence or malpractice;
• denial of services;
• billing disputes;
• collection actions;
• use or misuse of the Card; or
• participation in the program.

CONFIDENTIALITY AND INFORMATION SHARING

Applicant authorizes ISGH to collect and share limited information reasonably necessary to administer the program, verify eligibility, and coordinate referrals with Participating Providers, subject to applicable privacy laws and ISGH policies.

Applicant understands that ISGH is not a healthcare provider or covered entity for purposes of medical record management.

NO ENTITLEMENT OR GOVERNMENT BENEFIT

Participation in the program is voluntary and does not create any entitlement, vested right, governmental benefit, insurance coverage, or ongoing obligation by ISGH.

ACKNOWLEDGMENT

By signing below, Applicant acknowledges that:

• Applicant has read and understood these disclosures;
• Applicant has had the opportunity to ask questions;
• Applicant understands the Card is not insurance;
• Applicant understands ISGH does not provide medical care; and
• Applicant voluntarily applies for participation in the ISGH Health Access Card Program.

Applicant’s Signature: _____________________________________

Applicant’s Name: _____________________

Date: ________________________________