GALAXY HEALTH NETWORK MEDICAL SAVINGS CARD HOSPITAL TERMS AND CONDITIONS

Participating Galaxy Health Network Hospitals (GHNH) are available to provide MEMBERs services at less than RETAIL PRICE. Amount saved may vary. By utilizing the GHNH program, MEMBER agrees to the terms and conditions of this Membership Agreement and acknowledges and consents to the release of medical information to Galaxy Health Network as necessary to provide Eligible Services.

DEFINITIONS

A) MEMBER shall mean the person who has purchased the membership, including all tax deductible/ legal dependent family members of the MEMBER who has been accepted by the GHNH program. GHNH has the right to decline or renew any membership.

B) ADMINISTRATOR shall mean the Galaxy Health Network Hospital (GHNH) program.

C) ELIGIBLE SERVICES shall mean access to medical SAVINGS, which is capable of being provided by GHNH through participating FACILITIES and PROVIDERs.

D) FACILITY shall mean any ancillary or hospital that provides eligible services to MEMBERs.

E) PROVIDER shall mean any physician or healthcare professional that provides eligible services to MEMBERs.

F) RETAIL PRICE shall mean the usual and customary fees charged by a participating FACILITY and/or PROVIDER.

G) SAVINGS shall mean any amount less than the RETAIL PRICE charged by a FACILITY or PROVIDER. Amount saved may vary.

GENERAL PROVISIONS

The General Provisions of the GHNH program are as follows:

A) BEST EFFORT. GHNH shall use its best efforts to enlist an adequate number of PROVIDERs who will agree to provide Services to its MEMBERs. However, GHNH does not assume any obligation if the PROVIDER Network is not sufficient to serve MEMBERs’ needs.

B) OUT-OF-NETWORK PROVIDER. If a MEMBER selects an OUT-OF-NETWORK PROVIDER, SAVINGS ARE MORE DIFFICULT, AND POSSIBLY UNAVAILABLE THROUGH THIS AGREEMENT. However, GHNH will utilize its resources to coordinate negotiations with the FACILITY and/or PROVIDER to obtain the best possible SAVINGS.

C) MEMBERSHIP CARD. MEMBER will be provided with a membership card. The MEMBER should present the membership card to provide proof of the right to services under this agreement. By using the GHNH membership card or services, MEMBER agrees to the terms of membership.

D) RELATED SERVICES. On occasion, additional charges may be received by GHNH relating to Services received by a MEMBER, such as lab or radiology services provided at the request of the selected PROVIDER. If such related charges are sent to GHNH, MEMBER authorizes GHNH to process an charges as a part of the original Services. Notification of any additional charges of such services shall be sent to the MEMBER in the customary manner.

E) PRE-CERTIFICATION/REFERRAL NUMBER. The GHNH program requires precertification and a referral number prior to services being rendered which GHNH Medical Savings Card (MSC) Representatives coordinate. For pre-planned services, SAVINGS ARE NOT AVAILABLE WITHOUT THE REQUIRED REFERRAL NUMBER. In the event of an “Emergency Room Visit”, MEMBERs must notify GHNH and receive a referral number within forty-eight (48) hours of said visit OR GHNH IS NOT RESPONSIBLE TO NEGOTIATE DISCOUNTS. IF A MEMBER FAILS TO OBTAIN PRECERTIFICATION OR REFERRAL NUMBER AND A CLAIM IS RECEIVED, THE CLAIM WILL BE RETURNED TO THE MEMBER AS “SELF-PAY” RESULTING IN THE MEMBER BEING RESPONSIBLE FOR ALL BILLED SERVICES IN FULL. MEMBERS MUST CALL 1-800-975-3322 TO PRE-CERTIFY AND RECEIVE A REFERRAL NUMBER.

F) PAYMENT. (1) MEMBERs will be responsible for any payment after either insurance and/or contracted discount is applied. This payment will be made directly to the FACILITY and/or PROVIDER of services. This payment will be coordinated by the GHNH MSC Department with the PROVIDER, patient, and insurance company (if provided). (2) MEMBERs have the option to secure payment using the following methods or any combination thereof as pre-approved by the FACILITY and/or PROVIDER: Cash, Check, Credit Card, Insurance Payment, Medical Savings Account Funds, or other Certified Funds. The FACILITY and/or PROVIDER, in advance of services being performed, must agree upon any needed payment arrangement. If payment arrangements are not preapproved or payment made in a timely manner, the contracted SAVINGS could be in jeopardy. (3) MEMBERs will receive an itemized statement listing services rendered, the contracted discount taken, and all applicable payments (i.e. insurance company), if information is provided.

G) CLAIM PROCESSING. MEMBERs must process their claim through GHNH before submitting the claim to an insurance carrier. MEMBERS ARE NOT ELIGIBLE FOR SAVINGS THROUGH GHNH IF THEY ASK A PROVIDER/FACILITY TO FILE AN INSURANCE CLAIM FOR THEM.

H) CANCELLATION BY THE ADMINISTRATOR (GHNH). GHNH reserves the right to decline or renew the membership of any MEMBER. Failure to pay regular membership fees will result in immediate cancellation of Services rendered by GHNH until the debt is resolved.

I) ENTIRE AGREEMENT. All provisions under this Agreement constitute the entire Agreement between GHNH and the MEMBER. If any provision is declared void under the law, that provision is severable and the remainder of this Agreement shall remain in full force and effect.

J) LEGAL ACTION. If either party brings any legal action to this Membership Agreement it is expressly agreed that the party in whose favor final judgment is rendered shall be entitled to recover from the other party reasonable attorney's fees in addition to any other relief that may be awarded. Venue of any action to enforce this Agreement shall be Tarrant County, Texas and this Agreement shall be construed in accordance with the laws of the State of Texas.

K) LIABILITY. GHNH only provides reduced fees with FACILITIES and/or PROVIDERs through which MEMBERs may receive SAVINGS. GHNH does not provide any medical treatment, medical services, products, product liability, or guarantees of any kind for any MEMBER. FACILITIES and/or PROVIDERs are independent contractors and are not employees or agents of GHNH. The final selection of the FACILITY and/or PROVIDER and the approval or disapproval of medical treatment is the MEMBER’s choice alone. It is the MEMBER’s responsibility alone to perform due diligence (investigation) of any FACILITY and/or PROVIDER the MEMBER chooses to use. GHNH shall not interfere with the PROVIDER-MEMBER/Doctor-Patient relationship and assumes no responsibility for any medical advice given by any participating FACILITY and/or PROVIDER. GHNH shall not be liable for the negligence or other wrongful acts or omissions of any FACILITY and/or PROVIDER providing services pursuant to this Agreement. The MEMBER shall have no recourse against GHNH by reason of its availability for referral to FACILITIES and/or PROVIDERS. Upon occasion a FACILITY and/or PROVIDER may offer special pricing for services, or MEMBERs may be eligible for SAVINGS through other programs. MEMBERs have the option of choosing to pay the FACILITY AND/OR PROVIDER directly or utilizing an alternate program instead of the GHNH program. If the GHNH program is not used, and the fees charged are greater than the amount quoted by the FACILITY and/or PROVIDER or through an alternate program, GHNH shall not be liable to the MEMBER for the difference and no refunds will be issued.

L) ARBITRATION. In the event either MEMBER or GHNH brings an action against the other to enforce the provisions of this Agreement, such action shall be resolved by arbitration in Arlington, Texas, USA. Under the rules of the American Arbitration Association, with each party hereto appointing one arbitrator and the two appointed arbitrators appointing a third arbitrator. The arbitrators will have no authority to award any punitive or exemplary damages, or to vary or ignore the terms of this Agreement, and will be bound by controlling law. The parties acknowledge because this Agreement affects interstate commerce the Federal Arbitration Act applies. The majority decision of the three arbitrators shall be binding upon the parties hereto.The hospital product works with insurance, but also works as a point-of-service stand alone product. MEMBERs must provide information about the product they purchased when calling the Galaxy Health Network Hospital (GHNH) program Medical Savings Card (MSC) department. The Galaxy Health Network Hospital (GHNH) program is NOT insurance, but will coordinate services with insurance products if MEMBERs have purchased this service. The GHNH program is not intended to take the place of insurance.
MEMBERs can locate a participating PROVIDER by calling 1-800-975-3322 or visiting our website at G-WebAddress