ANNEX B

Revised December 2015

January 19, 2023

PHILIPPINE HEALTH INSURANCE CORPORATION

17th Flr., City State Centre Bldg.,
Shaw Blvd., Pasig City

SUBJECT : Performance Commitment For Health Care Professionals (Revision 2)

Sir/Madam:

To guarantee our commitment to the National Health Insurance Program (“NHIP”), I

respectfully submit this Performance Commitment.

And for the purposes of this Performance Commitment, I hereby commit the following
representations:

A. Representation of Eligibilities
1. I am LARAE ANNE S. TRONCILLO, a Doctor of Medicine duly registered and
licensed to practice my profession by the Professional Regulation Commission (PRC)
with PRC No. 0114183_;
2. As a licensed professional, it is my responsibility that my license is updated and valid
all the time;
3. I am a member in good standing of the NHIP with an active membership in the NHIP
by regularly paying my PHIC premium contributions during the validity of my
accreditation as a health care professional;
4. Membership in professional organization (for physicians only)
I am member in good standing of __PHILIPPINE MEDICAL ASSOCIATION
regulating my profession;
5. I am affiliated with CADIZ CITY HEALTH OFFICE / CADIZ CITY HEALTH
OFFICE BIRTHING HOME / DR. RAMON B. GUSTILO HOSPITAL,
and have undergone credentialing and given appropriate privileges in the said
institution/s in accordance with their policies and procedures.

B. Compliance to Pertinent Laws/ Rules and Regulations/ Policies/ Administrative

Orders and Issuances
6. I understand, that as a health care professional of the said institution/s, I will follow
the policies of the said facility as long as it does not violate Statutory laws, Orders,
Circulars and such other policies, rules and regulations issued by the Department of
Health (DOH) and all other government agencies and instrumentalities governing the
practice of my profession.
7. I have read, understood and I am fully aware of the provisions of Republic Act
(RA)7875 as amended by RA 10606 including its Implementing Rules & Regulations
particularly that pertaining to and governing the extent and limits of the grant of my
privilege to be an accredited health care professional of the NHIP administered by the
PHIC.

C. Conduct and Undertakings of Participation in the NHIP

Performance Commitment For Health Care Professionals (Revision 2)
 Further, I hereby commit myself to the following:
8. I shall conduct myself strictly and faithfully in accordance with the provisions of the
Republic Act 7875 as amended as the National Health Insurance Law of the
Philippines including all its Implementing Rules & Regulations (IRR);
9. I shall strictly abide with all the implementing rules and regulations, memorandum
circulars, advisories, special orders and other administrative issuances issued by the
PHIC governing my accreditation;
10. I shall strictly abide with all Administrative Orders, Circulars and such other policies,
rules and regulations issued by the Department of Health (DOH) and all other
government agencies and instrumentalities governing the practice of my profession
and affecting my accreditation in the NHIP;
11. I shall strictly adhere and abide with all the pertinent statutory laws affecting the
practice of my profession and my participation in the NHIP including, but not limited
to, the Senior Citizens Act of 2003 (R.A. 10645), the Breastfeeding Act (R.A. 7600),
the Newborn Screening Act (R.A. 9288), the Cheaper Medicines Act (R.A. 9502), the
Pharmacy Law (R.A. 5921), the Magna Carta for Disabled Persons (RA 9442) and
all other laws that may thereafter be passed by the Congress of the Philippines or any
other authorized instrumentalities of the government.
12. I am fully aware and I hereby acknowledge that accreditation administered by the
PHIC is not a right but a mere privilege as provided under Section 31, Article VIII of
R.A. 7875 on the ‘Authority to Grant Accreditation’ by the PHIC;
13. I am fully aware and I hereby acknowledge that my accreditation being a mere
privilege extended by the NHIP, the grant of which may be continuous for as long as I
comply with the requirements within a particular period as may be determined by the
PHIC. I further acknowledge and accept that my accreditation including the
appurtenant benefits and opportunities incident thereto, being a mere privilege may be
withdrawn, suspended and/or revoked at any time during the term of my accreditation
as may be determined by the PHIC to protect the interests of the NHIP;
14. I am fully aware and I unconditionally acknowledge and agree that non-adherence to
guidelines or any violation of any provision of my commitment whether directly or
indirectly, shall constitute ‘Breach of the Performance Commitment’ and shall be a
ground at the discretion of the PHIC, to suspend, shorten, pre-terminate and/or
revoke my accreditation including the appurtenant benefits and opportunities incident
thereto at any time during the term of my accreditation as may be determined by the
PHIC to protect the interests of the NHIP;
15. I undertake that all qualified NHIP beneficiaries shall be given high quality of health
care service due them without delay and that I shall deduct without delay the correct
amount of chargeable benefits due to qualified beneficiaries upon discharge;
16. I am fully aware and I unconditionally acknowledge and agree that any indication(s),
adverse reports/findings of pattern(s) or any other similar incident which may be
indicative of any illegal, irregular, improper and/or unethical conduct or practice of
my profession may be a ground at the discretion of the PHIC, to suspend, shorten,
pre-terminate and/or revoke my accreditation including the appurtenant benefits and
opportunities incident thereto at any time during the term of my accreditation as may
be determined by the PHIC to protect the interests of the NHIP;
17. I am fully aware, knowledgeable and hereby agree to strictly conduct myself in
accordance with and in compliance to all the basic precepts and tenets of my
profession including all the laws, guidelines, policies and regulations regulating my
profession including all the ethical standards required and governing the exercise of
my profession;

Performance Commitment For Health Care Professionals (Revision 2)

 18. I shall promote and protect the NHI Program against abuse, violation and/or over-
utilization of its Funds and I will not allow our institution to be a party to any act,
scheme, plan or contract that may directly or indirectly be prejudicial to the Program;
19. I shall not directly or indirectly engage in any form of unethical or improper practices
as an accredited provider such as but not limited to solicitation of patients for
purposes of compensability under the NHIP the purpose and/or the end consideration
of which tends unnecessary financial gain rather than promotion of the NHIP thereby
ultimately undermining the greater interests and noble purpose of the NHIP;
20. I hereby undertake that I shall immediately report to the PHIC, its Officers and/or to
any of its personnel, any act(s) of illegal, improper and/or unethical practices of
institutional or professional health care providers of the NHIP that may have come to
our knowledge directly or indirectly;
21. I shall immediately and promptly make available upon request for PHIC purposes, a
listing of my schedule of professional fees readily available to PHIC Officers and
authorized personnel, members, dependents and/or representatives;

D. Administrative Investigations in the Exercise of the Privilege of Accreditation

22. I unconditionally recognize the authority of the PHIC, its Officers and personnel
and/or its duly authorized representatives to conduct administrative investigation
relative to the exercise of my privilege and conduct of my profession as an accredited
health care professional of the NHIP and knowing the diversity of my profession, I
fully welcome and understand if the investigation shall be done beyond the normal
business/operating hours;
23. I undertake that I shall fully cooperate and submit myself to any assessment to be
conducted by the PHIC relative to any findings, adverse reports, quality issues,
pattern of utilization and/or any other acts indicative of any illegal, irregular and/or
unethical practice of my profession as an accredited healthcare professional of the
NHIP that may be prejudicial or tends to undermine the noble purpose of the NHIP;
24. I undertake that I shall comply without delay any and all PHIC’s summons, subpoena,
subpoena ‘duces tecum’ and other legal processes;
25. I undertake that at any time during the period of my accreditation, upon request of the
PHIC, I shall voluntarily and unconditionally sign and execute a new ‘performance
commitment’ to continue my accreditation as the case may be, as a sign of my good
faith and continuous dedication and sincerity to comply with my Performance
Commitment, to support and promote the National Health Insurance Program being
administered by the Philippine Health Insurance Corporation.
26. Finally, I hereby declare under penalties of perjury that my above-stated statements
are true and correct without any conditions and free from misrepresentations.

Very truly yours,

_______________________
LARAE ANNE S. TRONCILLO, M.D.
0114183
02/12/2023

Performance Commitment For Health Care Professionals (Revision 2)

Additional provision for facility owner / member of the Credentialing and Privileging
Committee

1. I am the approving authority and/or member of the Credentialing and Privileging

Committee of the credentialing and privileging of the professionals of my/our
institution and have conferred upon myself privileges to practice the profession based
on the credentials as certified by the Professional Regulation Commission (PRC) and
the national association of health care professionals recognized by PRC.

_______________________
MARIA VICTORIA E. IBAÑEZ, MD
0093506
08/04/2024

Performance Commitment For Health Care Professionals (Revision 2)