MEMORANDUM OF AGREEMENT

KNOW ALL MEN BY THESE PRESENTS:

This Memorandum of Agreement (MOA) made and entered into this _____ day of
____________ at Manila, Philippines, by and between:

The DEPARTMENT OF HEALTH (DOH), a national government agency created and

existing under the laws of the Republic of the Philippines, with principal office address at San
Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, herein represented by HON. ENRIQUE
T. DUQUE, MD, in his capacity as Secretary of Health, and hereinafter referred to as the
DOH;

- And -

The ______________________ ,(Name of Foreign Mission Group/Foreign Hospital), a

foreign non-government organization, with principal address at
____________________________, herein represented by _______________________ in
his/her capacity as _____________, and hereinafter referred to as the PARTNER;

- And -

The _________________________, a government hospital, with a principal address at

__________________________________ herein represented by
____________________________ in his/her capacity as Chief of Hospital /Hospital Director,
and hereinafter referred to as the Recipient Hospital;

WITNESSETH

WHEREAS, the DOH, through the ADOPT A HOSPITAL PROGRAM, as a sustainable

way of implementing Foreign Surgical and Medical Mission (FSMM) in the Philippines, has
issued AO No. _______ s. Guidelines on Foreign Surgical Mission Program in Support of
Universal Health Care/Kalusugan Pangkalahatan;

WHEREAS, the ______________________ (Partner), who has been conducting FSMM in

the country, have expressed its intention to participate in this program by adopting the
____________________________;

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WHEREAS, the ________________________ Recipient Hospital, whose desire is to ensure
effective health care services for its populace has also agreed to participate in the program;

ARTICLE 1
OBJECTIVES

The general objectives of this Agreement is to strengthen health service delivery of the
Recipient Hospital.

Specifically, the Partner shall provide assistance to the Recipient Hospital which can be in the
form of:
1. Provision of voluntary health services through conduct of annual medical/surgical
missions, community-based promotive and preventive care and services or clinical
rounds at the Recipient Hospital
2. Enhancement of capacity of staff and technology transfer trough:
a. conduct of teaching programs/medical education lectures and mentoring
activities
b. opportunities for observation visits at the foreign hospital
3. Donation of required medicines, supplies, equipment and devices

NOW THEREFORE, premises considered, the parties shall have the following roles and
responsibilities:

A. Department of Health (DOH) shall:

Act as the over-all coordinator in the implementation of this MOA.

a. Oversee the actual conduct of FSMM

b. Facilitate the forging/signing of the MOA
c. Facilitate the issuance of clearance for the donation of medicines, medical
supplies and equipment by acting as the consignee of these donations
d. Provide assistance in identifying indigent beneficiaries during the conduct of FSMM

B. The Partner shall:

Provide voluntary health services through annual conduct of FSMM, hands on

clinical/operative services, capacity enhancements and educational lectures and
provide/donate the necessary logistics such as medicines, medical supplies
and/or equipment to the Recipient Hospital.

1. Designate a leader/head of mission who shall be responsible and accountable

for the selection of members /volunteers of its team for the mission.
2. Responsible for the authentication by the Philippine Embassy/Consulate of
the documentary requirements for the issuance of government permits and
clearances.
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 3. Lead the actual conduct and implementation of FSMM.

C. The Recipient Hospital shall:

The Recipient Hospital in coordination with the Partner shall develop an

implementation plan which shall identify the specific activities and
corresponding schedules.

1. Lead the preparations including patient identification and screening.

2. Provide technical assistance including logistics for the FSMM.
3. Ensure the availability of health human resource to assist during the conduct
of FSMM.
4. Takes care of post mission follow-up and patient care and referrals for post –
operative complications.
5. Submits post mission/FSMM completion reports

This Memorandum of Agreement shall be effective upon signing by the Contracting

Parties hereto.

IN WITNESS WHEREOF, the Parties hereto have hereunto set their hands on the date and
place above written.

_______________________ ____________________________ ______________________

ENRIQUE T. ONA, M.D.
Secretary of Health Director/Chief of Hospital Partner

________________________ ____________________________
Witness Witness

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 ACKNOWLEDGEMENT

Republic of the Philippines)

_____________________) SS.

Before me, this ________ day of _______, 2010 in the City of __________,
Philippines, personally appeared.

______________________________

______________________________

______________________________

Both known to me to be the same person who executed the foregoing instrument, and they
acknowledge that the same is their free and voluntary act and deed.

This instrument consisting of 3 pages on which the acknowledgement is written has been
signed on each and every page thereof by the parties.

WITNESS MY HAND AND SEAL, at the place on the date first written above.

DOC.: __________
Page No. _______
Book No. _______
Series of 2010

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