MEMORANDUM OF AGREEMENT

KNOWN ALL MEN BY THESE PRESENTS:

This MEMORANDUM OF AGREEMENT is entered into for the

Philippine Health Insurance Corporation’s (PhilHealth) Maternity Care Package by
and between:

The NAME OF LYING-IN FACILITY located at ADDRESS OF

THE LYING-IN FACILITY represented by its head of facility, NAME
OF THE REPRESENTATIVE, hereinafter referred to as “SERVICE
PROVIDER”;
-and-
The QUEZON MEDICAL CENTER under the PROVINCIAL
GOVERNMENT OF QUEZON, a government unit created and existing
under the laws of the Republic of the Philippines with principal address at
Provincial Governor’s Office Building, Belen Drive, Quezon Capitol
Compound, Perez Avenue, Barangay 10, Lucena City represented by
Governor HON. ANGELINA “DOKTORA HELEN” D.L. TAN, M.D.,
MBAH, herein referred as “QMC”;

WITNESSETH THAT;
WHEREAS, to ensure that quality care is provided for the patient, the
SERVICE PROVIDER is required to have QMC for referral and further
management of both mother and the newborn, needing higher levels of maternal
and neonate care, respectively;
WHEREAS, pursuant to the Department of Health (DOH) Memorandum
Circular (MC) No. 2009-0010 or the Adoption of the Manual of Operation on
Maternal, Newborn, and Child Health and Nutrition (MNCHN) in the
Implementation of Programs, Projects and other Initiatives for Women and Child
dated May 10, 2009, provides as a guide to officials, health managers and other
groups and professionals concerned to establish, put into operation and sustain a
responsive MNCHN service delivery network nationwide, or popularly known as
Basic Emergency Obstetric and Newborn Care (BEmONC) – Comprehensive
Emergency Obstetric and Newborn Care (CEmONC) network;
WHEREAS, QMC is a Philippine Health Insurance Corporation
(PhilHealth) accredited hospital and secondary hospital category;
WHEREAS, both parties have agreed that QMC shall accept patients
referred to by the SERVICE PROVIDER and provide appropriate needed care to
their patients.
NOW THEREFORE, for and in consideration of the foregoing premises,
the herein parties agreed to the following terms and conditions:

1
 ARTICLE I
DEFINITION OF TERMS

1. MATERNITY CARE PACKAGE PROVIDER – PhilHealth Outpatient

Benefit Package that covers payment for the following services for the
second to fourth low-risk pregnancies, prenatal care, normal birth, routine
newborn care, postpartum care, and family planning rendered by the Phil
Health-accredited outpatient Clinic.

2. LOW-RISK PREGNANCY – a pregnancy with no identified risk factors.

Normal birth is defined as labor and delivery. The infant is born
spontaneously in the vertex position between 37-40 completed weeks of
pregnancy. After birth, mother and infant are both in good condition.

3. REFERRAL HOSPITAL – refers to QUEZON MEDICAL CENTER

(QMC), a government hospital under the PROVINCIAL GOVERNMENT
OF QUEZON, that is a PhilHealth-accredited Level 2 hospital that provides
health services and equipment needed for the management of obstetric or
newborn complications.

4. SERVICE PROVIDER – Outpatient Clinic which refers to NAME OF

LYING-IN FACILITY duly accredited by the Department of Health
(DOH) with License to Operate (LTO). It is a non-hospital outpatient
facility with adequate facilities.

5. REFERRAL – refers to the process by which the SERVICE PROVIDER

directs the patient to the REFERRAL HOSPITAL (QMC) caused by
onset risk and other emergency cases, for further management of patient’s
care.

ARTICLE II
OBLIGATIONS OF THE SERVICE PROVIDER

The SERVICE PROVIDER shall:

1. Render prenatal care, birth/delivery, routine newborn care and postpartum

services to female beneficiaries during their second to fourth low-risk
pregnancies and normal deliveries.

2. Be available to attend to all eligible patients at all times, especially during

Intrapartum.

3. Be abiding by complying with prescribed clinical pathways and practice

guidelines for the maternity Care Package.

4. Provide a pregnancy risk assessment during the first prenatal visit of the
patient. Any patient who presents with any of the following EXCLUSION
CRITERIA shall be referred to QMC for obstetric complications at the
soonest possible time.

4.1. History of previous major obstetric/gynecological operative

interventions (e.g. Cesarean Section, Salpingectomy for Ectopic
pregnancy, oophorectomy)

2
 4.2. History of three (-3) or more miscarriages, or one (1) stillbirth
4.3. Maternal age under 19 years old
4.4. Elderly primigravida (primis) with maternal age of 35 years old
4.5. Multiple pregnancy (e.g., twins, triplets, etc.)
4.6. Abnormal fetal presentation (e.g., breech)
4.7. Placental abnormalities (e.g., low-lying placenta, placenta
previa)
4.8. Uterine abnormalities (e.g. myoma uteri)
4.9. Ovarian abnormalities (e.g., ovarian cyst)
4.10 . History of medical conditions (e.g., hypertension, heart
disease, diabetes, thyroid disorder, obesity, moderate-severe
asthma, pre-eclampsia, epilepsy, renal disease, bleeding
disorder)
4.11 . Other risk factors that may arise during present pregnancy
(e.g. premature contractions, vaginal bleeding) that the service
perceives to warrant a referral to an obstetrician/physician for
further management.

5. In the event that the patient develops a risk factor during the course of the
present pregnancy, or should the patient require Intrapartum referral for
obstetric emergencies (e.g. preterm labor, prolonged labor, fetal distress,
and abruptio placenta) the SERVICE PROVIDER shall refer the patient
immediately to QMC in obstetrics for further management and/or delivery.

6. In all cases of referrals, the SERVICE PROVIDER shall accurately

accomplish and complete the PATIENT referral form. Moreover, the
SERVICE PROVIDER shall be physically present when making
intrapartum and postpartum referrals to QMC.

7. SERVICE PROVIDER must provide their own ambulance/vehicle to

transport their patients and relatives to QMC.

8. SERVICE PROVIDER must provide QMC a copy of its training

certificates from DOH BEmONC for obstetrician/gynecologist, doctor,
midwife, nurse, or a diplomate or fellow certificate from Philippine
Obstetrical and Gynecological Society.

9. Be autonomous and has direct responsibility and liability for its own
judgment and actions.

ARTICLE III
OBLIGATIONS OF THE REFERRAL HOSPITAL (QMC)

The QMC shall:

1. Accept ALL patients referred to by the SERVICE PROVIDER, subject to

proper submission of required forms and documents.

2. Accept referrals on a 24-hour basis for obstetrics/gynecologic/neonatal

emergency cases.

3. Be entitled to reimbursement of claims in accordance with existing NHIP

in-patients benefits, except under the Maternity Care Package.

4. Not entertain telephone consultations from the SERVICE PROVIDER.

3
 ARTICLE IV
LICENSES, PERMITS AND WARRANTIES

The SERVICE PROVIDER agrees to observe the internal rules and

regulations of the QMC, subject to the terms and conditions of its licenses and
permits as well as to comply with all existing laws, executive and administrative
orders issued by the competent authority.

The SERVICE PROVIDER warrants that it has all the requisites legal
authority and government approvals, permits and/or licenses to comply with its
obligations under this AGREEMENT and agrees to indemnify and hold the QMC
free and harmless against any and all claims, damages, demands and/or liabilities
arising out of in any way caused by or connected with the breach of warranty.

ARTICLE V
NO EMPLOYER-EMPLOYEE RELATIONSHIP

The herein parties further agree and accept that there will be no
employer/employee relationship between them during the tenure of this Agreement.

ARTICLE VI
LIMITATION OF LIABILITY

Either Party shall hold the other free and harmless against, and shall
indemnify the other from, any complaint, or liability arising from its failure to
comply with its promise or obligations under this AGREEMENT.

ARTICLE VII
TERM AND TERMINATION

This MEMORANDUM OF AGREEMENT shall take effect on the 1st of

January 2023 and shall continue in full force until 31st of December 2023 unless
terminated by either party through a service of seven-day notice to the other party.

In case of any violation of the terms and conditions herein stipulated by the
party, the non-defaulting party may terminate this Agreement by giving written
notice of termination to the defaulting party at least seven (7) days prior to the
intended date of termination.

The agreement will be deemed automatically terminated if the defaulting

party does not remedy the breach to the satisfaction of the non-defaulting party
before the lapse of the said seven (7) days period. This is without prejudice to the
filling of actions to protect the rights of the aggrieved party.

ARTICLE VIII
MISCELLANEOUS PROVISIONS

4
 1. Neither party shall disclose to any THIRD PARTY the confidential
information of the other party without the prior written consent of said
party.

2. Each party shall not indemnify and hold harmless the other party
from and against all claims, proceedings, losses, liabilities, damages, cost
and expenses which may be suffered or incurred by such other party arising
out of or in connection with negligence, breach of obligation, willful
misconduct of the party or any of its directors, officers or agents under this
Agreement.

3. The PARTIES agree to hold meetings or consultations at regular

intervals for the purpose of discussing, reviewing and resolving issues
relating to this Agreement. The parties agree to work together in good faith
and to amicably settle any dispute, controversy or claim arising out of or in
connection with this Agreement.

4. Any amendment or waiver of any provision found in this Agreement

shall require prior consent of both parties hereto.

5. Any dispute arising out of this Agreement shall be brought before

the appropriate courts of Quezon Province.

IN WITNESS WHEREOF, the PARTIES have set their hands to this

MEMORANDUM OF AGREEMENT this ____________ day of ____________,
2023 at Lucena City, Quezon, Philippines.

NAME OF LYING-IN FACILITY QUEZON MEDICAL CENTER

(PROVINCIAL GOVERNMENT OF
QUEZON)

By: By:

_________________________ ______________________________________
NAME OF THE REPRESENTATIVE HON. ANGELINA “DOKTORA HELEN” D.L. TAN, MD, MBAH
Position in the Lyin-in Facility Governor

SIGNED IN THE PRESENCE OF:

_____________________________________ _________________________________________________________
JUAN EUGENIO FIDEL B. VILLANUEVA, MD, MBAH, FPCHA
Chief of Hospital, Quezon Medical Center

BELEN T. GARANA, MD, FPOGS, FSGOP AUGUSTINA M. CABANGON, MD, FPPS

Head, Obstetrics and Gynecology Department Head, Pediatrics Department

5
 ACKNOWLEDGEMENT

Republic of the Philippines)

) S.S.

BEFORE ME, a Notary Public, for and in ________________ this ______________

personally appeared the following person with their respective community tax certificate number
to with:

GOV. ANGELINA “DOKTORA HELEN” D.L. TAN, MD, MBAH NAME OF REPRESENTATIVE

Res. Cert. No. _____________ Res. Cert. No._____________

Issued at: _________________ Issued at: ________________
Issued on: ________________ Issued on: ________________

Both known to me to be the same person who executed the foregoing instrument and
acknowledged the same were their free voluntary act and deed and that of the contractor/agency they
represent.

This document of six (6) pages including this page upon which this acknowledgement is
written, signed by the parties and their instrumental witness in the space provided for their signature
on the left-hand margin on each and every page thereof.

IN WITNESS WHEREOF, I have hereunto set my hand, the day, year and place above
written.

Doc. No. __________

Page No. _________
Book No. _________
Series of _________