AFFILIATION CONTRACT

BASE HOSPITAL CATEGORY CONTRACT

KNOW ALL MEN BY THESE PRESENTS:

This agreement is made and executed at the

__________________________________ this ___________ day of _______________
20__ by and between.

The VICTORIANO LUNA MEDICAL CENTER (VLMC), with post office address
at Armed Forces of the Philippine Health Service Command, V. Luna Ave, Quezon
City, represented herein by COL JONNA D DALAGUIT MC (GSC) in his capacity as
Commanding Officer with office at V. Luna Avenue, Quezon City, duly authorized for the
purpose and herein after known and referred to as PARTY OF THE FIRST PART;

and

The _____________________________________ is an institution created and

operating in accordance with the laws of the Republic of the Philippines, with the
principal office at ___________________________ in his capacity as the
________________________hereinafter known and referred to as PARTY OF THE
SECOND PARTY;

WITNESSETH

WHEREAS, under existing AFP regulations, the PARTY OF THE FIRST PART
JONNA D DALAGUIT DOMINGO A CHUA JR JENNUFER Y MATEO

has been designated as Training Hospital where Medical and Allied Health Students
MC

can be afforded the necessary training in fulfillment of statutory requirement for the
completion of their respective courses and prior to their taking the Government
sponsored board examination.
(GSC)MAJ
Chief, VLMCChief Medical Service, VLMC Head, DPL

WHEREAS, the PART OF THE SECOND PART, is the desirous of utilizing the
facilities of the PARTY OF THE FIRST PART for the training of its MEDICAL
TECHNOLOGY students, hereby agrees to affiliate with the PARTY OF THE FIRST
MC

PART; THE PARTY OF THE FIRST PART shall also be designated as “AFFILIATING
HOSPITAL” in compliance with CHED requirements.
MC (GSC)COL

NOW, THEREFORE, for and in consideration of the foregoing premises, the

contracting parties hereto mutually agree on the following terms and conditions;
COL

1. Responsibilities of the FIRST PARTY:

1.1 Provides the maximum opportunity for the students to gain

experience and training utilizing all available materials and equipment of the hospital,
without impairing its services to the patients. To permit the attendance of students in
specified activities of the affiliation program.
1.2 To orient the Deans, Clinical Instructors, preceptors and students of
the different colleges universities with the implementing rules and Guidelines of the
Hospital.
1.3 To enforce rules and regulations regarding the admission,
supervision and training of students, as prescribed by existing DND/AFP and concerned
unit regulations. The Commanding Officer, VLMC, upon the recommendation of the
 concerned head of Department, shall terminate the contract or the affiliation program
activities of those who commit acts detrimental to the health, safety and welfare of its
patients and personnel.

2. Responsibility of the PARTY OF THE SECOND PART:

a. To submit to the hospital a certified list of students, and clinical

areas where they are to undergo raining on or before ten (10) working days before the
start of training.
b. To assume the responsibility of the care of its students in case of
illness or injury during the course of affiliation/training.
c. To replace and/or repair any damages to or loss of equipment,
instrument and any of the hospital’s properties caused by their students school
representatives, either by carelessness, negligence, or bad faith.
d. To provide for didactic instruction of students as required.
e. To coordinate with the commanding officer through the concerned
head of department regarding the rotation of assignments, training and discipline of
students and other matters pertinent to affiliation program.
f. To abide with the policy guidelines/rules and regulation pertaining
to affiliation with ____________.
g. To defend the rights of the hospital in cases of suit that may be filed
by any student and or for any liability arising or resulting from claims of any nature, for
the death, injuries or damages that may be suffered by its students arising or in
connection with their affiliation.

3. LIMITATION OF AFFILIATES:
JONNA D DALAGUIT DOMINGO A CHUA JR JENNUFER Y MATEO

The total number of student affiliates accepted for training shall conform with the
MC

standards set forth by CHED, DOH and AFP regulations and shall not exceed the
number deemed commensurate to the training facilities available and number of
personnel involved in training in a particular ward/ section/ area of the hospital.
(GSC)MAJ

4. Affiliation Fees:
Chief, VLMCChief Medical Service, VLMC Head, DPL

THE PARTY OF THE SECOND PART shall contribute or donate a nominal sum
MC

of TEN THOUSAND PESOS (P10,000.00) as institutional fee and an affiliation fee in

the amount of TWO HUNDRED PESOS (P200.00) per student/month or fraction of a
MC (GSC)COL

month.

There will be two (2) checks for the payment of affiliation fee, one (1) check
addressed to CO, VLMC with the amount equivalent to 55% of the sum computed
affiliation fee and the other check to CO, 12 th FSU with the amount equivalent to 45% of
COL

the sum of the computed affiliation fee. The Affiliation fee is to be paid within fifteen (15)
working days upon the receipt of billing statement.

The institutional fee will have (1) check payment addressed to CO,VLMC. This is
to be paid thirty working days before the start of the school year.

Non-payments of affiliation and institutional fees beyond the specified dates of

payment shall be a ground for cancellation / revocation/non-renewal of affiliation / base
hospital contract.
 5. General Policies

a. At no time shall the interest and welfare of the patients be subordinate to

the conduct of the affiliation training program.
b. No special rooms or space shall be designated for the exclusive use of the
affiliating students nor shall new construction be made by the Center out of government
funds for the same purpose.
c. All affiliating students shall be governed by rules and regulations
regarding the conduct of training prescribed by the concerned medical facility.
d. The affiliating colleges and schools will be screened based on the school’s
performance and other criteria set forth by concerned medical facility.
e. Schools whose Permit to Operate / Accreditation had been cancelled/
terminated or not renewed by the appropriate government agency for this purpose shall
be a cause for the immediate termination/nullification of this contract.
f. This agreement may be terminated upon the initiation of their arty
however, a Termination Notice should be served sixty (60) days before the effective
date of termination, except as provided in para 5 E.
g. This agreement shall be effective for a period of one (1) school year
starting first semester subject to renewal upon consent of the PARTIES.
h. Next batch of students of schools that had not paid the affiliation fees on
designated period shall not be allowed to start clinical exposure until after settlement of
bills.

EFFECTIVITY AND DURATION OF AGREEMENT:

This contract shall take effect first semester of the School Year ___________
20___ to _____________ 20___.

IN WITNESS WHEREOF, the parties have hereunto affixed their signatures.

AFP Medical Center

_______________________
(Party of the First Part) (Party of the Second Part)

By: By:

JONNA D DALAGUIT ____________________

COL MC (GSC) ____________________
Chief, VLMC ____________________

SIGNED IN THE PRESENCE OF: SIGNED IN THE PRESENCE OF:

DOMINGO A CHUA JR ____________________

COL MC (GSC) ____________________
Chief, Medical Service -VLMC ____________________

JENNIFER Y MATEO ____________________

MAJ MC ____________________
Head, DPL ____________________
 ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) S.S

Before me, Notary Public in and for _____________________ personally

appeared ______________________________ WITH Resident Certificate No.
________________________ issued at _______________________ on Resident
Certificate No. ______________________ issued at ________________________ on
____________________ both known to me to be the same persons who executed the
foregoing agreement and they acknowledgement before me that they signed the same
of their own free will accord. WITNESS MY HAND AND SEAL ON THIS
________________________________ day of _________________ 20___ at
________________________________.

____________________________
Notary Public

Doc No. ____________________

Page No. ___________________
Book No. ___________________
Series of ___________________
JONNA D DALAGUIT DOMINGO A CHUA JR JENNUFER Y MATEO
(GSC)MAJ MC
Chief, VLMCChief Medical Service, VLMC Head, DPL
COL MC (GSC)COL MC