MEMORANDUM OF AGREEMENT

KNOW ALL MEN BY

hereinafter referred to as the “First Party”;

-and-

_________________________of legal age, Filipino and a resident of

_________________________________________________________________________________,
hereinafter referred to as the ;

-WITNESSETH-

WHEREAS, it is the basic right of all patients to receive, and the primary responsibility of the
Medical Specialist to render, hospital services of the highest quality, equitable, cost-effective;
WHEREAS, all admitted patients in the Hospital are under the direct care of resident
physicians who are, in turn, under the direct supervision of the different Medical Specialists;
WHEREAS, the Hospital recognizes the inviolable right of every patient confined in its Pay
Ward/Private Room to contract and engage the services of any hospital-accredited Medical Specialist
of their choice;
WHEREAS, the
1. to enter into a contract for professional services with patients confined or seeking
confinement to the Pay Ward/ Private Rooms in the Hospital.
2. Whenever available, all diagnostic and therapeutic procedures shall be performed within the
Hospital and the Medical Specialist must prescribe drugs and medicines that are available
in the Hospital’s pharmacy.
3. The Medical Specialist shall abide by, and comply with, all the rules, norms, policies and
regulations of the Department in which he belongs and of the Hospital in areas such as, but
not limited to, the use of all its staff and personnel including its facilities, equipment and
offices. The Medical Specialist shall also be under the supervision of the Department Chair
where his/her specialization falls.

4. The Medical Specialist shall fully and in plain language explain to the patient and/or his
immediate relatives, the terms and conditions of his professional contract. In emergency
cases, all measures must first be exhausted and the patient stabilized before any discussion
on the professional contract is done.
5. No deposit or down payment of professional services shall be made as pre-condition to the
rendition of any medical services by the Medical Specialist.
6. Professional fees for the clinical and ancillary services shall be collected at the Cashier’s
Office only
7. Patients with insurance benefits/HMO privileges shall shoulder all bills in excess of these
benefits/privileges.
8. Any patient who signifies his/her intention to transfer from the Pay Ward/Private Room to
the charity ward shall be allowed to do so, provided;
a. It is not on the day of discharge.
b. He/she settles all bills before transfer
c. He/she undergoes proper patient re-classification following Administrative Order No.
51-A, Series of 2011

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9. No patient shall be refused discharge because of unpaid or unsettled professional bills.
10. This agreement shall be effective starting ---------and an early termination or renewal of the
same is an exclusive prerogative of the management. Any party intending to renew/extend
this agreement shall notify the other party of his/its intention to do so in writing within
thirty (30) days prior to the date of expiry.

11. That it is understood that this contract does not create an employer-employee relationship
between the FIRST PARTY and the SECOND PARTY, that the services rendered
hereunder are not considered and will not be accredited as government service, and that the
latter is not entitled to benefits enjoyed by the regular personnel of the FIRST PARTY;
12. The SECOND PARTY shall not, whether during the effectivity of this contract or after its
termination for whatever reason, use, disclose or distribute to any person or entity, any
confidential information both of the patient and the FIRST PARTY, messages and other
data obtained by the SECOND PARTY during the contractual employment without prior
written consent
13. arise, the parties herein agree that the same shall be exclusively filed before a court of
competent jurisdiction in the City of Bacolod only to the exclusion of other courts.

IN WITNESS WHEREOF, we have set our signatures this ______ day of

_____________________, 20____ in Bacolod City, Philippines.

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES )

City of Bacolod ) S.S.

BEFORE ME, a Notary Public for and in the city of Bacolod, personally appeared the
following persons, with their identification documents as follows:

Name Gov’t. Issued ID Date/Place Issued

JULIUS M. DRILON
CECILIA P. LABRA

known to me and to me known to be he same persons who executed the foregoing

Memorandum of Agreement and who acknowledged to me that the same is their free and
voluntary act and deed.

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 This document consists of four (4) pages including this page of which the
acknowledgment is written, and is signed by the parties on each and every page and by their
instrumental witnesses on the left hand margin of each page.

WITNESS MY HAND AND SEAL on the date and place first above-written.

________________________
Notary Public

Doc No. __________

Page No. __________
Book No. __________
Series of 20 ________

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