Intellicare { YOUR INTELLIGENT HEAL Dear Doctor: We are privileged to inform you that, ASALUS CORPORATION offering to the public INTELLICARE, an integrated healthcare service program, has selected you as Health Care Provider effective upon receipt of notice of your acceptance. Please signify your acceptance of this nomination by affixing your signature below. Send this back to us through our Coordinator: Should you have any queries, please feel free to call us at tel. nos. 789-4000. Name and Signature Very truly yours, GERARDO J. JIAO, M.D. , MBAH Medical DirectorTel No, 7804000 Fax No 694-5864 e-mai: winnie, Intellicare U 7h Flor, Felaa dg. VA. Rusino St, Legasp Vilage, Maat City toh DOCTOR AFFILIATION DATA FORM. | [LAST NAME IFIRST NAME MIDDLE NAME OWE ADDRESS PHONE® MOBILEW [BIRTH DATE [CIVIL STATUS GENDER E-MAIL ADDRESS [SPECIALIZATION [SUB-SPECIALTY |PRC LICENSE NO, REGISTRATION DATE VALID UNTIL [PRILHEALTH ACCREDITATION NO: VALIDITY EXPIRATION IPMANO, PTR [sz [TAX PAYER ID NO. [TAX STATUS: Kindly put a check mark (¥) IVAT Registered: ‘VAT Exempt E-VATNO. Percentage Tax Others NAME OF HOSPITAL: [CLINIC SCHEDULE ROOM NO [TELIFAX NO. IMEDIGAL SECRETARY i MEMBERSHIP IN HEALTH ORGANIZATIONS & SPECIALTY SOCIETIES. love LEASE NOTIFY NTELICARE AS SOON AS POSSBLE OF JW CHANGES I YOUR NAME, MOBLEPHONE HOMER, HOSPITAL ‘SIGNATURE. DATE SIGNEDPROVIDER'S AGREEMENT Affiliated Physician's Contract This PROVIDER'S AGREEMENT, entered into this at Makati City, by and between: ASALUS CORPORATION, a corporation duly organized and existing under and by virtue of Philippine Laws, with office and postal address at 7" Floor Feliza Bldg., V. A. Rufino St., Legazpi Village, Makati City, Philippines, also known under the name and style “INTELLICARE”, herein represented by its Medical Director, GERARDO J. JIAO, M.D., MBAH, and hereinafter referred to as INTELLICARE; -and- oR. Filipino, of legal age, with office located at duly authorized to render medical, surgical and/or hospital care, hereinafter referred to as the AFFILIATED PHYSICIAN. WITNESSETH: That, WHEREAS AFFILIATED PHYSICIAN is a Medical Doctor duly authorized to render medical, surgical and/or hospital care and accredited with the various Specialty Boards of Medical and Surgical societies of which he is a member, WHEREAS, INTELLICARE is a Health Maintenance Organization capable of providing health care services to the public and pursuant to its business needs the professional services of AFFILIATED PHYSICIAN to provide quality service to enrolled members, companies, institutions and large groups/associations; WHEREAS, INTELLICARE has offered for accreditation and AFFILIATED PHYSICIAN has accepted the accreditation INTELLICARE to render professional service in and around a service area; NOW, THEREFORE, for and in consideration of the mutual premises, covenants and stipulations herein contained, the parties hereto have agreed, and do hereby agree as follows: |. RESPONSIBILITIES OF AFFILIATED PHYSICIAN 1. The AFFILIATED PHYSICIAN agrees to attend to INTELLICARE members admitted under his care, as referred by the INTELLICARE Coordinator, and to monitor the condition and care of the member to the best of his/her judgment and discretion. 2. The AFFILIATED PHYSICIAN shall timely and properly accomplish the RCS 1 & 2 including the diagnosis, signature of patient, attending physician and coordinator. The AFFILIATED PHYSICIAN shall strictly adhere to the "NO SIGNATURE, NO PAYMENT POLICY" which is hereby strictly implemented, 3. All professional fees due to the AFFILIATED PHYSICIAN which are payable by INTELLICARE are subject to withholding tax rates 4. Philhealth benefits on AFFILIATED PHYSICIAN's fee shall go to the attending AFFILIATED PHYSICIAN. 5. It is agreed that NO ADDITIONAL PROFESSIONAL'S FEES shall be charged to INTELLICARE members. In case the INTELLICARE member has exceeded his/her maximum benefit imit, the AFFILIATED PHYSICIAN agrees to charge the approved RVS Rates. Violation of this provision would be grounds for the termination of this contract. 6. The 12% Value Added Tax (VAT) shall be shouldered by INTELLICARE provided doctors submit VAT registration certificates 7. The AFFILIATED PHYSICIAN agrees to hold INTELLICARE, its stockholders, directors, officers, agents, successors-in-interest, assigns and all parties at interest therein or thereon, whether named or not named, free and harmless from any and all claims, demands, debts, dues, liens, actions or causes of action, at law or in equity, now held, ‘owned or possessed by AFFILIATED PHYSICIAN or by his heirs, successors-in-interest10, "1 | and assigns arising from or related to or concerning, either directly or indirectly, proximately or remotely, without being limited to but including his affiliation / accreditation with INTELLICARE, or for any claim of or liability to third person whether in contract, tort, or otherwise arising out of or related to any of the AFFILIATED PHYSICIAN'S acts of omission This Agreement shall be valid and effective from date of signing and for a period of four (4) years subject to one year renewals every time without necessity of formal renewal and execution of new contract every year. Nonetheless, this Agreement may be terminated after giving the other party thirty (30) day prior written notice. The AFFILIATED PHYSICIAN shall not directly or indirectly transfer, assign, or convey his rights and interest in this Agreement without prior written consent and approval of INTELLICARE. No right of interest shall be conferred by the AFFILIATED PHYSICIAN upon anyone by virtue of such unauthorized transfer. ‘Any change in the corporate name of INTELLICARE shall not invalidate the terms and conditions of this Agreement as signed by the parties under the name "INTELLICARE”, provided that the AFFILIATED PHYSICIAN has not transferred, conveyed or assigned his rights under this Agreement or that the Agreement has not been sooner terminated with oF without cause. INTELLICARE and the AFFILIATED PHYSICIAN are entirely separate and independent entities and the relationship between the two is strictly contractual. Neither party is the agent or employee of the other. Nor are the employees of each party employees of the other. SCHEDULE OF FEES FOR AFFILIATED PHYSICIAN | 1. The AFFILIATED PHYSICIAN accepts that the INTELLICARE rates shall not be lower than the rates agreed in the Memorandum of Agreement between AHMOPHI and the Specialty Boards of the Medical and Surgical Societies, 2. For medical procedures listed in the Philippine Health Insurance Corporation (Philhealth) and Philippine College of Surgeons (PCS) handbook of 2001, as amended in 01 April 2009, Intellicare agrees to pay professional fees based on the current/prevailing PHIC Relative Value Scale (which is currently the 2009 RVS). 3. The AFFILIATED PHYSICIAN hereby agrees with the following schedule of Professional Fees: | 3.1 MEDICAL | a) Out-patient consultations shall be paid with the following rates: - PHP 400.00/consultation. Other fees, exclusive of PHIC rates are as follows: > Routine CP Clearance - PHP 800.00 > CP Clearance with Medical Condition - PHP 1,000.00 > Intra-operative monitoring - PHP 1,400.00 b) In-patient daily visits shall be paid based on the type of program/accommodation as follows: * The following PCP rates will be effective on June 07, 2017. Implementation of new rate is subject to AHMOPI provision as endorsed by your Medical Association. WARD - PHP 600.00 SEMI-PRIVATE - PHP 750.00 PRIVATE - PHP 850.00 SUITE - PHP 1,200.00 ICUICCU - PHP 1,400.003.2 SURGICAL a) Out-patient Consultation = P400.00 b) The Surgeon shall be paid based on the Philippine College of Surgeon's RVS 2009 with the following multipliers: OPD/ WARD PHP 120/unit SEMI-PRIVATE — PHP 125/ unit PRIVATE — PHP 130/ unit SUITE — PHP 135 / unit Example: Appendectomy RUV 100 x 120 = PHP 12,000.00 TABHSO RUV 200 x 120 =PHP 24,000.00 Tonsillectomy RUV 100 x120 = PHP 12,000.00 TURP RUV 250 x 120 = PHP 30,000.00 Cataract Extraction w/ 1OL (Phacoemulsification) RUV 200 x 120 Cholecystectomy Ruv 200 x 120 PHP 24,000.00 PHP 24,000.00 * All approved secondary surgical procedures shall be paid 50% of the designated RVS ©) In-patient daily visits. shall_be paid based on the type of program/accommodation as follows: WARD. - PHP 550.00 SEMI-PRIVATE - PHP 650.00 PRIVATE - PHP 700.00 SUITE - PHP 1,100.00 ICUICCU - PHP 1,300.00 d) The following are the Assistant Surgeon's Fee: a. Operations with an RVS of at least 250 units b. Diplomate/Fellow - 25% of Surgeon's Fee c. Non-Specialist Physician - 10% of Surgeon's Fee ) Anesthesiologist shall be paid 50% of Surgeon's Fee. f) The duly accomplished RCS and Statement of Account must be submitted to Intellicare within three (3) months from the date the servicels wasiwere rendered. IN WITNESS WHEREOF, the parties hereto have signed on the date and place first above written. ASALUS CORPORATION / INTELLICARE Hospital/Clinic By: GERARDO J. JIAO, M.D., MBAH Affliated Physician Medical Director ‘SIGNED IN THE PRESENCE OF: EDMUND V. JOSE Senior Manager ~ Medical Relations Department