MEMORANDUM OF AGREEMENT
BETWEEN THE SIARGAO ISLAND MEDICAL CENTER
AND
THE MUNICIPALITY OF GENERAL LUNA, SURIGAO DEL NORTE
FOR THE SERVICE DELIVERY NETWORK (SDN) OF OUTSOURCED SERVICES
KNOW ALL MEN BY THESE PRESENTS:
SIARGAO ISLAND MEDICAL CENTER, a health Referral Facility under the
Department of Health, with office address at Barangay 1, Poblacion Dapa, Surigao del Norte,
represented herein by its Medical Center Chief DR. CHLOE C. DIGAL, hereinafter referred to
as the “Referral Facility”
-And-
GENERAL LUNA PRIMARY CARE FACILITY, a government entity created by
virtue of Philippine Laws under the Local Government Unit of General Luna, Surigao del Norte,
with office address at Old Tourism Road, Barangay 5 Poblacion, General Luna, Surigao del
Norte, represented by its Municipal Mayor, the HONORABLE JOHNSON Y. SAJULGA 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 provides various health care services to the
constituents of the town of Dapa, Surigao del Norte 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 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
1.1 Period of Delivery of Services – The Referral Facility shall commence the provision of
the delivery of services on July 15, 2025, 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 (4) hours from the time of submission except for the sputum microscopy and
pap smear where results shall be release after three (3) days and after seven (7) days
respectively;
1.3 The payment for referred diagnostic services shall be paid by the Konsulta Package
Provider within thirty (30) days 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 ______, 2025
ast ________, Surigao del Norte
General Luna Primary Care Facility Siargao Island Medical Center
By: By:
HON. JOHNSON Y. SAJULGA DR. CHLOE C. DIGAL
Mayor – Municipality of General Luna Medical Center Chief
DR. ARMAN CARL DULAY
Municipal Health Officer
ACKNOWLEDGMENT
Republic of the Philippines )
Province of Surigao del Norte ) s.s.
BEFORE ME, a Notary Public for and in the above jurisdiction this __th day of _____,
2025 personally appeared:
Name Competent proof of identity Place and date of issue
DR. CHLOE C. DIGAL ________________________ ____________________
HON. JOHNSON Y. SAJULGA ________________________ ____________________
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 acknowledgment 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 2025
