PATIENT’S NAME RELATIONSHIP TO CONTRIBUTOR’S IP NO.

BED DOA DOD YOB

CONTRIBUTOR ID/NHIF NO. NO.

NATIONAL HEALTH INSURANCE FUND

P.O. BOX 7468-00610
EASTLEIGH, NAIROBI
SUNRISE (MEGA) MALL

HOSPITAL NAME: DATE:

I hereby confirm that the information given above is true and authentic to the best of my knowledge.
SURVEILLANCE OFFICER: 1. SIGNATURE:
2. SIGNATURE:

HOSPITAL REPRESENTATIVE: SIGNATURE:

HOSPITAL STAMP: BRANCH OFFICE STAMP: