ee - . i Ata Yate. time Yoru Revised 2020, ‘NATIONAL HOSPrTAt SURANCE FUND 1, Box 30443-00200, RALRORE Tel (020) 2791248/50 Website wort nhiter ke Ema oor ke CLAIM FORM Claim No. I PLEASE BE AS COMPRENENSTE AND ACCURATE AS POSSIOLE REN COMPLETO Tits CLA FORM. ERRORS OR OMISSIONS MAY DELAY CLAM PAYMENTS, Member No: Members ID No: ‘Scheme: Patient Name: (Last, First, Middle) TD No/Binth Cort/ County: Notification No: Relationship to Member: 0 Self © Spouse © Chad) Other | Phone No: ‘hae: 7M) | Gender ‘Do you have any other MEDICAL Incurance cover? Yes (No | IFYES, detals of plan cover: aclity Name: Hospital Code ‘Admitting Pracitioners Name & Registration No: Tyee Pationt Nez ‘Bed Chair Nez ‘Treatment Details C) Inpatient © Outpatient Mert Dp: 2 ee ss, For outpationt services, Date of service is the Date of admission. 16D 107 Dateot | Datoof | Case Bill Claim ea ‘code | Procedure Description Low wa = Total “Any unforeseen circumstances or additional information that led to an increased length of stay for tbis admission? D. PATIENT’S/ AUTHORIZED PERSON'S DECLARATION: | certify that ! hove received the above treatment and that the above information Je correct. underst>nd that It is an offence to falsify information for purposes of ~>.~ining any benefit under NHIF Act. Names(Majina): 2 + Signature(Sehini:_s. <___ate(Tarehe}: __ E. HOSPITAL DECLARATION: This is to certify that to the best of my knowledge, the information contained above, and any ettechments provided is true, accurate, and complete end the service(s) rendered is necessary tothe heelth ofthe patient. ! understand that isan offence ‘tm knowingly make any false statement fr purposes of obtaining any benefit under NHIF Act. Please arrange to pay the hospital the sum of Kshs wu being the approved amount for services rendered. en . Facility stamp cee