1

MEMORANDUM OF AGREEMENT

KNOW ALL MEN BY THESE PRESENTS: This Memorandum, entered into this __________________, 2011, in Santa Cruz, Laguna, by and between-

HONORABLE ________________________, a member of the Congress of the Republic of the Philippines representing the Third (3rd) District of Laguna, with office address at Room S-513, House of Representatives, Constitution Hills, Quezon City, hereinafter referred to as the FIRST PARTY; -and-

___________________________, a duly organized and existing teaching and training medical institution of the Department of Health under the direct control and supervision of the PROVINCIAL GOVERNMENT OF

LAGUNA, with office address in _______________________, herein represented by the incumbent Chief of Hospital, ______________________, hereinafter referred to as the SECOND PARTY;

WITNESSETH:

WHEREAS, the FIRST PARTY, as moved by her intent to uplift, augment and enhance the health condition of her indigent constituents, resolved to implement a certain Medical Assistance Program (hereinafter referred to as the “PROGRAM”) encompassing the necessary hospitalization, medicine and other related medical services or expenses of indigent patients; WHEREAS, the SECOND PARTY has the sufficient facilities to provide the essential medical services for the indigent constituents (hereinafter collectively referred to as the “PATIENT”) of the FIRST PARTY and is willing to extend its close coordination and utmost cooperation for the effective and proper implementation of the PROGRAM; WHEREAS, the FIRST PARTY, in order to achieve and accomplish the PROGRAM for indigent patients, initially appropriated in favor of the SECOND PARTY an amount of ________________________(PhP ____________) emanating from her PRIORITY DEVELOPMENT ASSISTANCE FUND (PDAF) under Special Allotment Release Order (SARO) No. _______________ dated ___________________; WHEREAS, such sum of _________________________ (PhP ____________) allocated by the FIRST PARTY shall form part of the medical assistance fund (hereinafter referred to as the “FUND”) for the PROGRAM; NOW, THEREFORE, for and in consideration of foregoing premises, the herein parties agreed, as they hereby agree, upon the terms and conditions set forth as follows;

2

I. PROVISIONS FOR AVAILMENT OF THE PROGRAM

1. Being the PROGRAM of the herein FIRST PARTY, she has the exclusive discretion to determine and identify the PATIENT deserving to benefit from the PROGRAM through the facilities of the SECOND PARTY;

2. For this purpose, the PATIENT or his/her representative shall proceed to the designated

office of the FIRST PARTY to fill-up the prescribed form indicating his/her request for medical assistance;

3. Thereafter, an appropriate interview shall be conducted by the FIRST PARTY to

ascertain the entitlement of the PATIENT to avail of the PROGRAM;

4. In the affirmative, the FIRST PARTY or her authorized representative shall prepare, sign and issue in favor of the PATIENT the official Letter of Authorization (LOA, for brevity) or Letter of Recommendation (LOR, for brevity);

5. The PATIENT shall present and submit the LOA or LOR to the Office of the Chief of

Hospital of the SECOND PARTY, through the Department of Medical and Social Services, for referral to the appropriate hospital unit;

II. CORRELATIVITY PROVISIONS BETWEEN THE HEREIN PARTIES

1. The LOA or LOR shall be addressed by the FIRST PARTY to the Chief of Hospital of the

SECOND PARTY, through its Officer-in-Charge, containing, among others, the following primary details, to wit;

a) Full name of the patient; b) Control number; c) Validity period; d) Nature and extent of the medical assistance; e) Maximum assistance amount;

2. Sufficient number of copies of the LOA or LOR shall be issued by the FIRST PARTY or

her authorized representative to be furnished towards the appropriate department/s of the SECOND PARTY as may be deemed necessary depending upon the medical exigencies of the PATIENT as follows, to wit;

a) Pharmacy; b) Ward; c) Medical Social Services; d) Laboratory; e) X-Ray; f) Billing;

3. Upon submission of the LOA or LOR to the SECOND PARTY, the PATIENT shall be

referred to the proper hospital unit—Out-Patient Department or Emergency Room; 4. In case of issuance of any drug prescription, the PATIENT or his/her representative

shall submit the said prescription, together with the LOA or LOR, to the Pharmacy Department of the SECOND PARTY wherein the medicine price/s shall be indicated thereon;

5. Where necessity entails any laboratory service, the medical prescription and the LOA or

LOR shall be submitted by the PATIENT or his/her representative to the Department of

3

Medical and Social Services of the SECOND PARTY to indicate thereon the prescribed laboratory fee/s;

6. Upon indication of the corresponding price/s on the medical prescription/s, the

PATIENT or his/her representative shall present the same, together with the LOA or LOR, to the Accounting Department of the SECOND PARTY for appropriate action or for approval;

7. In the event that the PATIENT must be admitted for confinement, the same shall be

carried out at Charity Ward. And before discharge, the PATIENT or his/her representative shall present the LOA or LOR to the Billing Department of the SECOND PARTY for appropriate action or for clearance;

8. Medical assistance to in-patients, out-patients and emergency patients shall include

medicines, laboratory tests, ECGs, X-Rays, Ultrasound tests, other ancillary or diagnostic procedures and medical supplies for any necessary operation which are available from the SECOND PARTY;

III. CONTINGENCY PROVISIONS

1. In the event of lack of vacancy at the Charity Ward during emergency cases, the PATIENT shall be admitted to the cheapest possible room at the Pay Ward;

2. Admission in Suite Rooms and alike shall not be allowed under any circumstance, while

Private Rooms may only be availed of by the PATIENT upon prior written recommendation and authorization from the FIRST PARTY or her authorized representative;

3. Subject to availability of the FUND, in cases wherein prescribed medicines for confined

PATIENT shall be temporarily unobtainable from the Pharmacy Department of the SECOND PARTY, the same may be purchased by the SECOND PARTY from private drugstores. Any cost incurred thereto shall be refunded from the FUND on the condition that the purchase/s must be supported by pertinent Official Receipt/s and the aforesaid Pharmacy Department issued the corresponding certification of temporary unavailability therein of the prescribed medicine, a certified drug of the Philippine National Drug Formulary;

4. In analogous manner, whenever a breakdown of laboratory or diagnostic machines and

equipments of the SECOND PARTY occurred or in instances of inadequate medical facilities of the SECOND PARTY to perform indispensable medical procedures, the PATIENT may be referred by the SECOND PARTY to the appropriate private entities, provided that the FIRST PARTY authorized or approved in writing the medical referral issued by the SECOND PARTY. Any expense remunerated thereto shall be reimbursed from the FUND upon presentment of the pertinent Official Receipt/s;

IV. RENDITION OF ACCOUNTING

1. For monitoring and recording purposes of the FIRST PARTY, the Accounting Department of the SECOND PARTY shall regularly furnish the FIRST PARTY with a list of patients benefited by the PROGRAM, indicating the nature and amount of the medical assistance provided for by the SECOND PARTY;

2. Such itemized list prepared by the SECOND PARTY shall be submitted to the FIRST

PARTY on a regular monthly basis or on occasions wherein the FIRST PARTY made a written request therefor;

4

V. SEVERABILITY CLAUSE

If any portion or provision of this Memorandum is subsequently declared unconstitutional or void, the remaining portion or provisions thereof shall remain valid and effective until the attainment of the essential purpose of this Agreement.

VI. EFFECTIVITY CLAUSE

This Memorandum shall take effect upon signing of the herein parties and upon receipt by the SECOND PARTY of the Notice of Allocation (NCA) from the Department of Budget and Management (DBM) covering the particular appropriation contained herein and shall continue to be in full force and effect depending upon the availability of the FUND, subject to the proper replenishment by the FIRST PARTY. IN WITNESS WHEREOF, the parties have hereunto affixed their respective signatures

on the date and place first written above.

HONORABLE ____________________ First Party _________________________________ Second Party By: _____________________________ Chief of Hospital

WITH MY CONFORMITY:

HON. JEORGE “E.R.” EJERCITO ESTREGAN Provincial Governor

SIGNED IN THE PRESENCE OF:

___________________________ __________________________

5

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

________________________________)

BEFORE ME, a Notary Public for and in the Province of Laguna, this _______________,

personally appeared the following persons-

Name ID No.

____________ ________________________ ____________ ________________________ ____________ ________________________ known to me to be the same persons who executed the foregoing instrument and that they

acknowledged to me that the same is their own free act and voluntary deed.

This Memorandum of Agreement, consisting of five (5) pages, including this page

wherein this acknowledgment is written, has been signed by the parties and their instrumental

witnesses on each and every page thereof, and sealed with my notarial seal.

WITNESS MY HAND AND SEAL on the date and place above written.

Doc. No. ______; Page No. ______; Book No. ______; Series of 2011.