MEMORANDUM OF AGREEMENT

BETWEEN THE PROVINCIAL GOVERNMENT OF ILOCOS NORTE

AND
THE MUNICIPALITY OF ____________, ILOCOS NORTE

FOR THESERVICE DELIVERY NETWORK (SDN) ON OUTSOURCED SERVICES

KNOW ALL MEN BY THESE PRESENTS:

____________DISTRICT HOSPITAL, a health Referral Facility under the Local Government

of the Province of Ilocos Norte, with office address at Barangay ____________________,
______________, Ilocos Norte, represented herein by its Governor the HONORABLE MATHEW
JOSEPH MARCOS MANOTOC, hereinafter referred to as the “Referral Facility

-And-

” (Name of Municipality/City) RURAL HEALTH UNIT , a government entity created by

virtue of Philippine Laws under the Local Government Unit of ______________,Ilocos Norte, with
office address at Barangay ___________, ______________, Ilocos Norte, represented herein by its
Municipal Mayor, the Honorable _______________________ and hereinafter, referred to as the
“Konsulta Package Provider”;

WITNESSETH, that:

WHEREAS, there is a need to establish a partnership and referral system with other health
service providers/facilities in order to improve the delivery of quality health care to patients;

WHEREAS, the Referral Facility has a diagnostic facility capable of providing X-ray
examination services among others;

WHEREAS, the Referral Facility providing various health care services to the constituents of
the town of Tayug, Pangasinan and its nearby Municipalities;

WHEREAS, the Konsulta Package Provider does not have the complete facility to provide
diagnostic laboratory test and X-ray services which are essential component of Konsulta Package of the
NHIP;
WHEREAS, the Referral Facility agrees to provide the services to the patients of Konsulta
Package Provider based on the terms and conditions of the Agreement;

NOW, THEREFORE, for and consideration of the foregoing premises, the Parties hereby agree
as follows:

1. General terms and conditions:

The Referral Facility shall provide the following services to the patients referred by
the Konsulta Package Provider as follows:

DIAGNOSTIC LABORATORY TEST Unit Price T.A.T.

1. Chest X-Ray
2. CBC with platelet count
3. Urinalysis
4. Fecalysis
5. Sputum Microscopy
6. Fecal Occult Blood
7. Pap Smear
8. Lipid Profile (with total cholesterol, HDL and LDL
cholesterol, triglycerides)
9. FBS
10. OGTT
11. ECG
 12. Creatinine
13. HbA1c

WHEREAS, the Referral Facility shall provide the following Drugs/Medicine/Supplies to be

prescribed to the patients of the Konsulta Package Provider as follows:
1. Amoxicillin Anti-microbial
2. Co-Amoxiclav
3. Cotrimoxazole
4. Nitrofurantoin
5. Ciprofloxacin
6. Clarithromycin
7. Oral Rehydration Salt Fluid and Electrolytes
8. Prednisone Anti-asthma
9. Salbutamol
10. Fluticasone + Salmeterol
11. Paracetamol Anti-pyretics
12. Gliclazide Anti-diabetic
13. Metformin
14. Simvastatin Anti-dyslipidemia
15. Enalapril Anti-hypertensives
16. Metropolol
17. Amlodipine
18. Hydrochlorothiazide
19. Lozartan
20. Aspirin Anti-thrombotics
21. Chlorpheniramine Maleate Anti-histamine

1.1 Period of Delivery of Services – The referral Facility shall commence the provision of
the delivery of services on ____________________, 2023 and shall continue until and
unless terminated by either Party;

1.2 Place of Delivery of Services – The Referral Facility shall provide the Services for
Chest X-Ray and the other diagnostic laboratory examination samples/specimens will
be delivered by Konsulta Package Provider to the former, results shall be sent thru
email within four (1) hour from the time of submission;

1.3 The payment for referred diagnostic services and drugs/medicine/supplies shall be paid
by the Konsulta Package Provider within thirty (30) after receiving the billing
statement issued by the Referral Facility;

1.4 Warranty – The referral Facility represents and warrants that it will perform the
services with reasonable care and skill to the patients referred by Konsulta Package
Provider under this Agreement and will not infringe or violate any intellectual
property rights or right of any third party.

IN WITNESS WHEREOF, the parties have signed this Agreement this _____th of ____________,
2023 at _________________, Ilocos Norte.

_______________Rural Health Unit Provincial Government of Ilocos Norte

By: By:
HON. _________________________ HON. MATTHEW JOSEPH M. MANOTOC
Mayor- Municipality of ______, Ilocos Norte Governor

Signed in the presence of:

DR. __________________
Municipal Health Officer
______________________
DR. ROGELIO R. BALBAG
HEALTH OPERATIONS CONSULTANT
HON. _____________________
Vice Governor
____________________________
DR. JOSEPHINE RUEDAS
PROVINCIAL HEALTH OFFICER
 ACKNOWLEDGEMENT

Republic of the Philippines )

Province of Ilocos Norte ) s.s.

BEFORE ME, a Notary Public for and in the above jurisdiction this ___th day of
________, 2023 personally appeared:

Name Competent proof of identity Place and date of issue

HON. MATTHEW JOSEPH M. MANOTOC______________________ ____________________
HON. (Name of Mayor) _______________________ ____________________

Who appear to me in person and present an integrally complete instrument or document; and who
represent to me that the signatures on the instrument or document, consisting of three (3) pages,
including this page where the acknowledgement is written, was voluntarily affixed by them for the
purpose/s stated in the instrument or document; and declare that they have executed the instrument or
document as their free voluntary act and deed, and if they act in a particular representative capacity, that
they have the authority to sign in that capacity.

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

NOTARY PUBLIC

Doc. No. ____________

Page No. ____________
Book No ____________
Series of 2023