MEMORANDUM OF AGREEMENT

This Memorandum of Agreement executed on this 18th day of January, 2011

by and between

______________________________, a business entity, duly registered with the Department of

Trade and Industry with business address at Block 3 Lot 28 Intertownhomes Subdivision,
Barangay Ipilan, Tayabas City, Quezon Province and represented by the ownier / sole
proprietor SONIA RAÑESES-REYES, hereinafter referred to as the “SERVICE PROVIDER”

and

Quezon Medical Center, a medical and a corporate entity duly registered in accordance with the
laws of the Republic of the Philippines with business at Quezon Avenue, Lucena City
represented by its MEDICAL DIRECTOR, _______________________________, hereinafter referred to
as theREFERRAL HOSPITAL;

and

Doctor Ramon Baldovino, OB-GYNE,a medical Practitioner (OBSTETRICIAN-GYNECOLOGIST)

with licensed number_______, and _______________________________
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, ________________________________________ (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 PARTNERPHYSICIANS

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 ___________________________ 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 theprescribed clinical
pathways and practices guidelines for the Maternity Care Package.

4.The SERVICE PROVIDERshall do a pregnancy risk during the firstprenatal visit of the patient.

5.The SERVICE PROVIDER shall provide ambulance/vehicle totransport 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.
1.1History 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.
1.5Multiple 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.
In witness thereof we have affixed our names and signature this ____ day of January 2011 at
Lucena City.