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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 (3
rd
) 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;






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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 unitOut-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
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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;

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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:

___________________________ __________________________












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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.