Promissory Note Sample for Hospital Bill Philippines

INSTITUTIONAL PROMISSORY NOTE AND MEDICAL DEBT SETTLEMENT AGREEMENT

DOCUMENT ID: PN-MED-PH-2023-V1.0
EFFECTIVE DATE: [Effective Date]
VERSION: 1.0
GOVERNING JURISDICTION: Republic of the Philippines

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1. STATUTORY & LEGAL COMPLIANCE NOTICE

Legal Disclaimer: This instrument is drafted in accordance with the Civil Code of the Republic of the Philippines (Republic Act No. 386), the Revised Penal Code, and relevant administrative issuances of the Philippine Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth). This document constitutes an unconditional promise to pay a sum certain in money for medical, surgical, and hospital services rendered. Modification of this document without the express written consent of the Hospital's legal counsel may render it voidable or unenforceable under Philippine law.

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2. PARTIES & RECITALS

This Promissory Note and Medical Debt Settlement Agreement (the "Note") is entered into and made effective as of the [Effective Date], by and between:

THE CREDITOR:
[Hospital Full Legal Name], a medical institution duly organized and existing under the laws of the Republic of the Philippines, with principal place of business at [Hospital Principal Address] (hereinafter referred to as the "Hospital").

THE DEBTOR:
[Patient / Debtor Full Legal Name], of legal age, [Civil Status], with residential address at [Principal Address] and contact number [Contact Number] (hereinafter referred to as the "Maker").

(The Hospital and the Maker shall hereinafter be collectively referred to as the "Parties" and individually as a "Party".)

RECITALS:
WHEREAS, the Maker (or the Maker's dependent, [Patient Name if different from Maker]) was admitted to and received medical, diagnostic, therapeutic, and/or pharmaceutical services at the Hospital;
WHEREAS, the total hospital bill, inclusive of professional fees, room and board, medical supplies, and diagnostics, amounts to [Total Bill Amount in PHP] Philippine Pesos, against which partial payments, deposits, and statutory deductions (including PhilHealth and HMO benefits) amounting to [Deductions/Credits Amount in PHP] have been applied;
WHEREAS, the remaining unpaid net balance due and demandable by the Hospital stands at [Amount in PHP] Philippine Pesos (the "Principal Sum");
WHEREAS, the Maker acknowledges the validity, exactness, and justness of the Principal Sum and desires to settle the same through an installment arrangement, which the Hospital is willing to grant subject to the terms and conditions set forth herein;

NOW, THEREFORE, for and in consideration of the medical services rendered, the mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Maker unconditionally promises to pay to the order of the Hospital the Principal Sum, strictly in accordance with the following terms:

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3. EXHAUSTIVE OPERATIVE CLAUSES & LEGAL TERMS

Section 1. Promise to Pay and Principal Sum

For value received, the Maker unconditionally promises to pay to the order of the Hospital, at its main administrative office or via designated official electronic payment channels, the principal sum of [Amount in PHP] Philippine Pesos ([Amount in Words]), together with interest accrued thereon as provided in Section 2 hereof.

Section 2. Compensation, Amortization, and Payment Terms

1. Schedule of Payments: The Principal Sum shall be amortized and paid in equal consecutive monthly installments over a period of [Number of Months] months, commencing on [First Due Date], and continuing on the same day of each succeeding month until fully paid, as detailed in the amortization schedule below:
   • Installment Frequency: [Monthly / Bi-Weekly]
   • Installment Amount: [Amount per Installment in PHP] Philippine Pesos
   • Final Due Date: [Final Maturity Date]
2. Late Payment Penalties: Any installment not paid within [Number] days from its due date shall be subject to a delinquency surcharge/penalty interest at the rate of [Interest Rate, e.g., 1% to 3%] per centum per month, computed from the date of default until the date of actual payment, without prejudice to the Hospital’s right to declare the entire remaining balance immediately due and demandable.
3. Application of Payments: All payments made under this Note shall be applied first to the payment of accrued penalties, then to accumulated interest, and the remainder to the reduction of the Principal Sum.
4. Method of Settlement: Payments shall be made in Philippine Currency via Cash, Manager’s Check, Company Check (subject to clearing), or official electronic fund transfers directed to the official designated bank account of the Hospital. No payment shall be recognized unless covered by an official provisional or final receipt issued by the Hospital’s Cashier or Treasury Department.

Section 3. Term, Maturity, and Acceleration Clause

1. Term: The term of this Note shall commence on the Effective Date and shall automatically terminate upon the full settlement of the Principal Sum, accrued interest, and penalties, if any.
2. Acceleration of Maturity: If the Maker fails to pay any installment within [Number, e.g., 15] calendar days from its due date, or if the Maker becomes insolvent, makes an assignment for the benefit of creditors, files for bankruptcy, or if any material misrepresentation was made by the Maker in connection with this Note, the entire unpaid Principal Sum, together with all accrued interest and penalties, shall, at the sole option of the Hospital and without the necessity of demand, protest, or further notice (all of which are hereby expressly waived by the Maker), become immediately due and payable.

Section 4. Collateral, Suretyship, and Guaranty (If Applicable)

To secure the prompt and faithful payment of this Note, the Maker has provided:

• A Deed of Real Estate / Chattel Mortgage over property located at [Property Address].
• A joint and several guarantee executed by [Name of Co-Maker / Guarantor], of legal age, residing at [Co-Maker Address], who, by signing below as Co-Maker, explicitly binds themselves solidarily (solidariamente) with the Maker for the full and faithful compliance of all obligations under this Note pursuant to Articles 2047 and 2055 of the Civil Code of the Philippines.

Section 5. Representations and Warranties

The Maker hereby represents, warrants, and covenants to the Hospital that:

1. The Maker has the full legal capacity, power, and authority to execute, deliver, and perform their obligations under this Note.
2. The execution and delivery of this Note do not violate any law, administrative regulation, or court order applicable to the Maker.
3. The medical services for which this debt is incurred were duly received, and the total amount stated herein is a true, correct, and uncontested obligation.
4. All personal data and financial information provided by the Maker to the Hospital are authentic, accurate, and compliant with the Data Privacy Act of 2012 (Republic Act No. 10173).

Section 6. Limitation of Liability and Hospital Retained Rights

1. Nothing in this Note shall be construed as a waiver, novation, or modification of the Hospital's statutory rights under Philippine laws governing retention of patients or release of medical records, except as expressly provided herein.
2. The Maker acknowledges that this Note is executed voluntarily to secure the discharge of the patient and/or the release of official billing statements and necessary medical certificates, and does not constitute a waiver by the Hospital of any civil or criminal remedies available under Philippine jurisprudence for fraudulent contraction of obligations.

Section 7. Default, Attorney’s Fees, and Cost of Collection

Should the Hospital refer this Note to an attorney or collection agency for collection, or file suit in court to enforce the same, the Maker shall pay, in addition to the unpaid Principal Sum, interest, and penalties, an additional amount equivalent to twenty-five percent (25%) of the total amount due as and for attorney’s fees, which in no case shall be less than [Minimum Fee in PHP] Philippine Pesos, plus all costs of suit and judicial expenses authorized by the Rules of Court of the Philippines.

Section 8. Dispute Resolution and Venue

1. In the event of any dispute, controversy, or claim arising out of or relating to this Note, the Parties shall first use their best endeavors to settle such disputes amicably through good-faith negotiation within fifteen (15) days from receipt of written notice by one Party to the other.
2. If amicable settlement fails, any legal action, suit, or proceeding arising out of or relating to this Note shall be instituted exclusively in the proper courts of [City/Municipality where Hospital is located], the Maker hereby expressly waiving any other venue privileges under the Rules of Court.

Section 9. Governing Law

This Promissory Note shall be governed by, construed, and enforced in accordance with the substantive laws of the Republic of the Philippines, without regard to its conflict of laws principles.

Section 10. Miscellaneous Provisions

1. Severability: If any provision of this Note is held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, such provision shall be modified to the minimum extent necessary to make it valid and enforceable, and the remaining provisions shall remain in full force and effect.
2. Waiver: No failure or delay by the Hospital in exercising any right, power, or privilege under this Note shall operate as a waiver thereof, nor shall any single or partial exercise preclude any other or further exercise of any right, power, or privilege.
3. Entire Agreement: This Note constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior oral or written negotiations, commitments, term sheets, and understandings.
4. Amendments: No modification, amendment, or waiver of any provision of this Note shall be valid unless executed in writing and signed by both authorized representatives of the Hospital and the Maker.
5. Binding Effect: This Note shall be binding upon and endure to the benefit of the Parties hereto and their respective heirs, executors, administrators, successors, and permitted assigns.

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4. EXECUTION & FORMAL SIGNATURE BLOCKS

IN WITNESS WHEREOF, the Parties have caused this Promissory Note to be duly executed by their respective authorized representatives as of the Effective Date first written above.

FOR THE CREDITOR ([Hospital Full Legal Name]):

Signature: _____________________________________
Printed Name: [Authorized Signatory Name]
Title: [Title / Role, e.g., Chief Financial Officer / Billing Director]
Company: [Hospital Full Legal Name]
Date: [Date]

FOR THE DEBTER / MAKER:

Signature: _____________________________________
Printed Name: [Patient / Debtor Full Legal Name]
Title: Maker / Patient
Date: [Date]

FOR THE CO-MAKER / SOLIDARY SURETY (If Applicable):

Signature: _____________________________________
Printed Name: [Co-Maker Full Legal Name]
Title: Guarantor / Solidary Co-Maker
Date: [Date]

SIGNED IN THE PRESENCE OF:

Signature: _____________________________________
Printed Name: [Witness 1 Printed Name]

Signature: _____________________________________
Printed Name: [Witness 2 Printed Name]

ACKNOWLEDGMENT

(Republic of the Philippines)
(City of [City] ) S.S.

BEFORE ME, a Notary Public for and in the jurisdiction aforesaid, personally appeared the above-named persons with their competent evidence of identity as follows:

• [Authorized Signatory Name] – Government ID Type: [ID Type] No. [ID Number] issued on [Issue Date] at [Issuing Place]
• [Patient / Debtor Full Legal Name] – Government ID Type: [ID Type] No. [ID Number] issued on [Issue Date] at [Issuing Place]

Known to me to be the same persons who executed the foregoing Promissory Note and acknowledged to me that the same is their free and voluntary act and deed, as well as that of the institution they represent.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal this [Day] day of [Month], [Year] at [City/Municipality], Philippines.

Doc. No. ________;
Page No. ________;
Book No. ____;
Series of 20.

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5. STEP-BY-STEP EXECUTION & FILING GUIDE

1. Document Preparation:

   • Open this template in Microsoft Word or Google Docs.
   • Perform a global search and replace (or manual edit) to populate all bracketed fields (e.g., [Hospital Full Legal Name], [Amount in PHP], [Effective Date]) with precise operational data. Ensure all figures match the final hospital billing statement.

2. Signatory Verification:

   • Verify that the Maker presents a valid Philippine government-issued identification card (e.g., Passport, UMID, Driver’s License, PhilSys National ID) matching the details entered in the Acknowledgment section.
   • If a Co-Maker or Solidary Surety is required pursuant to Section 4, ensure the guarantor is physically present or provides verified notarized authorization.

3. Execution & Notarization:

   • Under Philippine law, promissory notes intended for judicial execution and ease of collection are highly recommended to be notarized. Both the Maker and the Hospital's authorized representative (along with the Co-Maker, if applicable) must sign the document in the presence of a Notary Public.
   • Ensure the Notary Public affixes their official seal and completes the Acknowledgment block.

4. Digital Execution (Alternative):

   • If utilizing enterprise digital signature platforms (e.g., DocuSign, Adobe Sign), ensure that the platform complies with the requirements of the Electronic Commerce Act of 2000 (Republic Act No. 8792) of the Philippines, capturing digital certificates, timestamps, and audit trails.

5. Record Retention & Archiving:

   • The Hospital's Billing and Credit & Collection Department must retain the Original Notarized Hard Copy in a secure, fireproof vault or physical archive file corresponding to the Maker's account number.
   • A digital scanned copy in PDF/A format must be indexed and uploaded to the Hospital's Electronic Health Record (EHR) / Enterprise Resource Planning (ERP) financial module linked to the patient's ledger.
   • Provide a duplicate original copy to the Maker for their personal financial records.