Sample Memo Agreement

MEMORANDUM OF AGREEMENT
This Memorandum of Agreement executed on this _____Date ________ at Silang

Cavite, Philippines by and between.
----, a business entity duly registered with the Department of Trade and Industry with
business address at ---- and represented by the ownier / sole proprietor----, hereinafter
referred to as the “SERVICE PROVIDER”
and
NAME OF HOSPITAL, a medical and a corporate entity duly registered in accordance
with the laws of the Republic of the Philippines with business at KM 43 By Pass, Silang,
Cavite represented by its MEDICAL DIRECTOR, NAME OF DOCTOR/OWNER, hereinafter referred
to as the REFERRAL HOSPITAL;
and
NAME OF OB-GYNE, a medical practitioner (OBSTETRICIAN-GYNECOLOGIST) with licensed
number_______, and NAME OF PEDIATRICIAN, a medical practitioner (PEDIATRICIAN) with
License No. ________, both are presently affiliated at name of hospital, hereinafter referred
to as the “PARTNER PHYSICIANS”.
Witnesseth
WHEREAS, Jullienne Lying-In and Maternity Clinic (SERVICE PROVIDER) is engaged in
the service of providing maternity care to pregnant women offering prenatal, midwife-
assisted delivery and post natal care to mothers and newborns;
WHEREAS, there are onset risk cases which the SERVICE PROVIDER can handle better
with the help of professional medical practitioners after examination of patients and
determination that they will require further adept medical supervision for both mothers and
newborns;
WHEREAS, the parties herto – the SERVICE PROVIDER and PARTNER PHYSICIANS
forge a partnership concerning onset risk cases to facilitate patients admission to the
REFERRAL HOSPITAL bearing in mind the best interest of the mother and the unborn or
newborn, as the case may be;
WHEREAS, all onset risk cases handled by herein SERVICE PROVIDER and PARTNER
PHYSICIANS shall be exclusively referred to the REFERRAL HOSPITAL subject to Philhealth
membership of patients or beneficiaries;
WHEREAS, the trilateral relationship is meant to maximize the Maternity Care
Package available to Philhealth members and their beneficiaries and make available its
availment to a wider patient base;
WHEREAS, essentially, the purpose of this Memorandum of Agreement is to extend
the REFERRAL HOSPITAL’S accreditation use to the SERVICE PROVIDER in relation to onset
risk cases.
NOW THEREFORE, for and in consideration of the foregoing premises, the
hereinafter parties have agreed to the following terms and conditions.
TERMS AND CONDITIONS

Article I
DEFINITIONS OF TERMS
1. The Maternity Care Package is a PhilHealth Outpatient Benefit Package that covers
payment for the following services for the first and second low-risk pregnancies,
prenatal care, normal birth, routine newborn care, postpartum care, and family
planning, rendered by the PhilHealth-Accredited Outpatient Clinic.
2. Low-risk pregnancy with no identified risk factors. Normal birth is defined as

spontaneous is onset, low-risk at the start of the labor, and remaining so throughout
labor and delivery. The infant is born spontaneously in the vertex position between
37 and 40 completed weeks pregnancy. After birth, mother and infant are in good
condition.
3. The REFERRAL HOSPITAL is a PhilHealth-Accredited secondary or tertiary hospital

equipped with state-of-the-art medical instruments and equipments needed for the
management of obstetric or newborn complications.
4. The SERVICE PROVIDER is an outpatient and a business entity known as JULLIENNE

LYIN-IN AND MATERNITY CLINIC duly accredited by PhilHealth for the Maternity Care
Package. It is non-hospital outpatient facility with adequate facilities and
competently trained staff capable of providing all the maternal and neonatal
services.
5. REFERRAL is the process by which the SERVICE PROVIDER directs the patient to the
REFERRAL HOSPITAL due to onset risk, for further management of patient’s care.
6. PARTNER PHYSICISIANs are highly qualified medical practitioners in their own field of
profession (OBSTETRICIAN-GYNECOLOGY and PEDIATRICIANS) who will provide
further management of the mother and the new-born baby.
Article II
OBLIGATION OF THE SERVICE PROVIDER
1. The SERVICE PROVIDER shall render prenatal, birth delivery, routine newborn care,
and postpartum services to female beneficiaries during their first and second low-
risk pregnancies and normal deliveries.
2. The SERVICE PROVIDER shall be available to attend to all patients at all times,
especially during intra-partum.
3. The SERVICE PROVIDER shall be abide by/comply with the prescribed clinical
pathways and practices guidelines for the Maternity Care Package.
4. The SERVICE PROVIDER shall do a pregnancy risk during the first prenatal visit
of the patient.
5. The SERVICE PROVIDER shall provide ambulance/vehicle to transport patients to the
referral hospital should an emergency arise related to complaints on
obstetric/gynecological/neonatal cases.
Article III
OBLIGATION OF PARTNER PHYSICIAN
1. The PARTNER PHYSICIANS in their own judgment and direction coordinate with the
SERVICE PROVIDER of any patients who presents with any of the EXCLUSIO CRITERIA
and if necessary shall refer the patients to the REFERRAL HOSPITAL for Obstetric
complication and at the soonest possible time.
1.1 History of previous major obstetric/gynecologic operative interventions (e.g.
caesarian Section, Salpingectomy for ectopic pregnancy, Oephorectomy).
1.2 History of three (3) or more miscarriages, or one (1) stillbirth.
1.3 Maternal age under 19 years old.
1.4 Elderly primis with maternal age of 35 years old.
1.5 Multiple pregnancy (e.g. twins, triplets, etc.,)
1.6 Abnormal fetal presentation (e.g. breech)
1.7 Placenta abnormalities (e.g. low-lying placenta, placenta previa)
1.8 Uterine abnormalities (e.g. myoma uteri)
1.9 Ovarian abnormalities (e.g. ovarian cyst)
1.10 History of medical conditions (e.g. hypertension, heart disease, diabetes,
thyroid disorders, obesity, moderate-serve asthma, pre-eclampsia, epilepsy,
bleeding disorders)
1.11 Other risk factors that may arise during present pregnancy (e.g. premature
contractions, vaginal bleeding), that the midwife perceives to warrant a referral
to an obstetrician / physician for further management.
2. The PARTNER PHYSICIAN and with the conformity of the REFERRAL HOSPITAL is
authorized to endorsed the patient of the SERVICE PROVIDER.
Article IV
OBLIGATIONS OF THE REFERRAL HOSPITAL
1. The REFERRAL HOSPITAL shall accept ALL patients properly referred by the SERVICE
PROVIDER.
2. The REFERRAL HOSPITAL shall accept referrals on a 24-hour basis for obstetric /
gynecologic/ neonatal emergency cases.
3. The REFERRAL HOSPITAL shall be entitled to reimbursement of claims in accordance

with existing NHIP in-patient benefits.
Article V
COMMON PROVISIONS
The herein PARTIES agree that their attendance to the patients shall be independent
of each other, hence, each PARTY shall be individually responsible for any incident that may
occur during the time the patient is under his/her care. The determination of the liabilities
of PARTIES in the care of the patients shall depend upon the specific factual circumstance all
around the patients.
IN WITNESS WHEREOF, the parties have hereunto signed this MEMORANDUM OF

AGREEMENT this _______Date_______ in Silang, Cavite.
Signed in behalf of the Service Provider RODELIZA F. EMPIALES

Jullienne Lying-in and Maternity Clinic
Signed in behalf of Referral Hospital NAME OF DIRECTOR/OWNER

Referral Hospital’s Name
Signed in behalf of the Partner Physician NAME OF THE DOCTOR

Obstetrician – Gynecologist
NAME OF THE DOCTOR

Pediatrician
WITNESS:
______________________________ _______________________________
ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINES
SILANG, CAVITE
BEFORE ME, this ____Date_ in the Municipality of Silang, Cavite, personally
appeared the following persons:
NAME PRC License No.
RODELIZA F. EMPIALES _____________
NAME OF DIRECTOR _____________
NAME OF OB-GYNE _____________
NAME OF PEDIATRICIAN _____________
known to me and to be the same persons who executed the foregoing instruments, and
acknowledged to me that the same is their voluntary act and deed.
These instruments consisting of four (4) pages, has been signed on the left margin of
each and every page thereof by the parties and their witness, and sealed with my notarial
seal.
WITNESS MY HAND AND SEAL in the place and on the date first above written.
Doc No. ____________

Page No. ____________
Book No. ____________
Series of 2010

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MEMORANDUM OF AGREEMENT

This Memorandum of Agreement executed on this _Date ____ at Silang

TERMS AND CONDITIONS

2. Low-risk pregnancy with no identified risk factors. Normal birth is defined as

3. The REFERRAL HOSPITAL is a PhilHealth-Accredited secondary or tertiary hospital

4. The SERVICE PROVIDER is an outpatient and a business entity known as JULLIENNE

3. The REFERRAL HOSPITAL shall be entitled to reimbursement of claims in accordance

IN WITNESS WHEREOF, the parties have hereunto signed this MEMORANDUM OF

Signed in behalf of the Service Provider RODELIZA F. EMPIALES

Signed in behalf of Referral Hospital NAME OF DIRECTOR/OWNER

Signed in behalf of the Partner Physician NAME OF THE DOCTOR

NAME OF THE DOCTOR

Doc No. ____________

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