Republic of the Philippines)

Province of Agusan del Sur) S.S.

Municipality of San Francisco)
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UNDERTAKING
WE, the MEDICAL PRACTITIONERS currently connected with San Francisco Doctors
Hospital Incorporated (SFDHI) with address at Barangay Hubang, San Francisco,
Agusan del Sur, having been duly sworn in accordance with law, do hereby depose and
state THAT;

1. We are holding our tour of duty and perform medical procedures in accordance to
our expertise at SFDHI;

2. We are knowledgeable of the existing Memorandum of Agreement between SFDHI

and the Department of Social Welfare and Development (DSWD) Caraga on the
provision of Medical Assistance through their Assistance to Individuals In Crisis
Situation by virtue of Memorandum Circular Number 24, Series of 2020;

3. Said policy provides that the Hospital Bill includes the payment for Professional Fees
and other services rendered to every patient being admitted for hospitalization;

4. For and in consideration of deciding the amount of assistance to be extended to

each patient by the Interviewing Social Worker of the DSWD Crisis Intervention
Section, the Professional Fees and hospital charges are included in the Hospital Bill;

5. We are giving our approval and consent to SFDHI and DSWD to include the amount
accorded in the Professional Fee as basis in deciding the amount for every patient;

6. The SFDHI shall be responsible in developing a system through the Medical Social
Worker to track the records and the Finance Unit for the payment thereof to the
Doctors;

IN WITNESS WHEREOF, we have hereunto set our hands this __ day of __________,
2022 at"_____________, Philippines.

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