Memorandum of Agreement

MEMORANDUM OF AGREEMENT
KNOW ALL MEN BY THESE PRESENTS:
This agreement executed this _____day of _______in Quezon City, Philippines,

by and between:
BARANGAY APOLONIO SAMSON, with office address

at Kaingin Road corner Old Samson Road, Barangay
Apolonio Samson, District 6, Quezon City, represented
herein by its Punong Barangay, HON. ELIZABETH C.
DE JESUS and hereinafter referred to as FIRST
PARTY.
- and -
EAST AVENUE MEDICAL CENTER, a government

hospital duly organized and existing in accordance with
law, with office address at East Avenue, Quezon City,
represented herein by its Medical Center Chief II
ROLAND L. CORTEZ, MD, MHA, CESO IV and
hereinafter referred to as the SECOND PARTY.
WITNESSETH: That
WHEREAS, the GENDER AND DEVELOPMENT PLAN for FY 2016 of the FIRST
PARTY has an appropriation in the amount of TWO HUNDRED THOUSAND PESOS (P
200,000.00) and the TASK FORCE ON YOUTH DEVELOPMENT PLAN has an
appropriation of TWO HUNDRED THOUSAND PESOS (P 200,000.00), for and as part of
their Medical Assistance Program intended for indigent patients who may be referred by
the FIRST PARTY to the SECOND PARTY;
WHEREAS, the FIRST PARTY is sought by the numerous indigent patients from
the First Party for assistance regarding their medical condition;
WHEREAS, the SECOND PARTY has the facilities to provide the services needed
by indigent patients requesting for Medical Assistance and is willing to
cooperate/coordinate and monitor the implementation of the PROGRAM; and
WHEREAS, a close coordination and cooperation between the parties to this

agreement are essential for the effective and proper implementation as well as
monitoring of the aforementioned appropriation.
NOW THEREFORE, in consideration of the premises and mutual promises and

agreement contained herein, the PARTIES hereto, intending to be legally bound to one
another, hereby agree as follows:
I. RESPONSIBILITIES OF THE PARTIES
A. The FIRST PARTY shall:
1. The FIRST PARTY shall identify indigent patients who may avail the benefits of
medical assistance as well as the extent of assistance that shall be extended to
them by the SECOND PARTY;
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2. The FIRST PARTY shall issue to the patient or to his representative/s a duly
signed GUARANTEE LETTER with indicated control number (sample copy of
which is hereto attached as Annex A hereof), addressed to the Medical Center
Chief II of the SECOND PARTY. The GUARANTEE LETTER will indicate the
maximum amount he can avail of; and
3. Expenses incurred shall be reimbursed by the FIRST PARTY after the SECOND
PARTY through its Billing Section has given the Patients Billing Statement and
copies of GUARANTEE LETTERS to the FIRST PARTY.
B. The SECOND PARTY shall:
1. Accept the indigent patient referred by the FIRST PARTY who will go to the Out-
Patient Department or Emergency Room as the case may be, for referral to and
check-up by the assigned Specialist. If he has been issued a prescription, he
shall proceed to the Pharmacy of the SECOND PARTY where the price of the
medicine is determined and indicated; and
2. The SECOND PARTY, through its Medical Social Service, shall furnish the FIRST
PARTY on a MONTHLY BASIS, with a list of patients who have availed of the
PROGRAM including the amount of assistance extended.
II. GENERAL GUIDELINES
1. If the referred patients by the FIRST PARTY need laboratory services, he will
present the GUARANTEE LETTER together with the request for the needed
procedures to the Laboratory Department of the SECOND PARTY. The
Laboratory Department of the SECOND PARTY shall indicate the amount;
2. In case of In-Patient, the referred patients will present the approved

GUARANTEE LETTER to the Medical Social Service of the SECOND PARTY before
discharge of the referred patients;
3. Medical Assistance to in-patients, out-patients and emergency patients may

include Medicines, Laboratory Tests, New Born Screening, Thyroid Scan, T3, T4,
Dialysis, ECG, X-Ray, Cobalt, and other medical and laboratory procedures as
may be recommended by the Specialist/Consultant of the SECOND PARTY;
4. All payments and releases under this PROGRAM of the FIRST PARTY shall be in
accordance with existing government accounting and auditing rules and
regulations; and
5. This Agreement shall be deemed effective thereof by both parties. This

Agreement shall continue to be effective until the FUND is completely exhausted
or unless otherwise amended by both parties in the Agreement.
III. TERMINATION
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Any violation of the foregoing covenant shall warrant the cancellation of this
Memorandum of Agreement upon written notice to the non-terminating parties for at
least Thirty (30) days.
IN WITNESS WHEREOF, the parties have hereunto put their hands in the place
and on the date first above-written.
BARANGAY APOLONIO SAMSON EAST AVENUE MEDICAL CENTER

by: by:
HON. ELIZABETH C. DE JESUS ROLAND L. CORTEZ, MD, MHA, CESO IV

First Party Second Party
Signed in the Presence of
__________________________ _________________________
Printed Name and Signature Printed Name and Signature
Page 3 of 4
ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.
BEFORE ME, a Notary Public, this _____ day of_____ , 2015 in Quezon City,
personally came and appeared the following with their respective competent evidence
of identification:
Name Competent evidence Date and Place

of Identity Issued
HON. ELIZABETH C. DE JESUS
ROLAND L. CORTEZ, MD, MHA, CESO IV
All known to me and to me known to be the same persons who executed the foregoing
instrument and they acknowledged that the same is their free and voluntary act and
deed, and that of the entities they respectively represent.
The foregoing instrument relates to a Memorandum of Agreement, consisting of

four (4) pages including the page on which this acknowledgment is written, and has
been signed by the parties and their instrumental witnesses, and sealed with my
notarial seal.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial

seal on the date and place above-written.
Notary Public
Doc. No. : _______;
Page No. : _______;
Book No.: _______;
Series of 2015.
Page 4 of 4

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KNOW ALL MEN BY THESE PRESENTS:

This agreement executed this _____day of _______in Quezon City, Philippines,

BARANGAY APOLONIO SAMSON, with office address

EAST AVENUE MEDICAL CENTER, a government

WHEREAS, a close coordination and cooperation between the parties to this

NOW THEREFORE, in consideration of the premises and mutual promises and

I. RESPONSIBILITIES OF THE PARTIES

A. The FIRST PARTY shall:

B. The SECOND PARTY shall:

II. GENERAL GUIDELINES

2. In case of In-Patient, the referred patients will present the approved

3. Medical Assistance to in-patients, out-patients and emergency patients may

5. This Agreement shall be deemed effective thereof by both parties. This

BARANGAY APOLONIO SAMSON EAST AVENUE MEDICAL CENTER

HON. ELIZABETH C. DE JESUS ROLAND L. CORTEZ, MD, MHA, CESO IV

Signed in the Presence of

REPUBLIC OF THE PHILIPPINES )

Name Competent evidence Date and Place

The foregoing instrument relates to a Memorandum of Agreement, consisting of

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial

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This agreement executed this _day of ___in Quezon City, Philippines,