Aya 11 15

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:
M H D I S T R I C T M U T
A Y A W A S O
S U B - M E T R O
0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Surname Other Names Date of Birth
S M I T H P R I S C I L L A 0 8 / 0 5 / 1 9 8 5
Hospital Record No Age
Gender Male Female
2 7
NHIS no. 3 8 5 8
M H C 0 / 0 1 4 9 0 0
Services Provided (to be lled by all health care providers)

Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision
DD/MM/YYYY 1 1 / 0 2 / 2 0 1 2 1 2 / 0 2 / 2 0 1 2
/ / / /
Absconded/Discharged against medical advice
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y
Specialty Description: O B S T E T R I C S - G Y N E C O L O G Y
Procedures(s) (to be lled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3
Spontaneous Vaginal Del
Date
1 1 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 3 A
Diagnosis(es) (to be lled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be lled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
Medicines (to be lled by all health care providers dispensing medicines) Price
. . . . .
Qty
Total Cost
. . . . .
Code
Client Claim Summary Type of Service

A B C D In-Patient Out-Patient Investigations Pharmacy
G-DRG/Code
O B G Y 3 3 A
Tari Amount
4 7 . 3 2 . . .
Signature
Name
(Health Facility Insurance Ocer)
TOTAL Scheme Use Only

Date Received Signed Action 1 Action 2
4 7 . 3 2
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
B O A K Y E D O R I S 1 5 / 0 9 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 1 5 3 3 1 1 7 8
M H B 4 / 0 2 8 2 8 6

DD/MM/YYYY 1 2 / 0 2 / 2 0 1 2 1 8 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Caesarian Section (DIST
Date
1 2 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 2 A
1 2 3 4 5
ICD-10
P 2 0 . 0
G-DRG
Intrauterine hypoxia first noted
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 2 A
Tari Amount
1 8 5 . 7 7 . . .
Signature
Name

1 8 5 . 7 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A D J E T E Y B E A T R I C E 0 1 / 0 7 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 7 3 9 8 0 9 6 1
M H B 7 / 0 0 4 5 1 1

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C
Specialty Description: A N T E - N A T A L
Procedures(s) (to be lled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
E S H U N M I L D R E D 1 9 / 0 4 / 1 9 8 4
Gender Male Female
2 8
NHIS no. A Y A 0 0 4 1 6 5
M H B 9 / 0 2 0 7 7 4

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D A D Z I E P H Y L L I S 1 0 / 0 1 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 5 2 0 6 7 9 8 1
M H B 9 / 0 2 3 3 1 0

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M E N S A H E R N E S T I N A 0 5 / 0 9 / 1 9 8 5
Gender Male Female
2 7
NHIS no. 7 8 5 0 5 9 4 3
M H C 0 / 0 0 0 3 8 9

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D O N K O R J U D I T H 1 4 / 0 8 / 1 9 8 6
Gender Male Female
2 6
NHIS no. 7 3 4 9 3 1 0 1
M H C 0 / 0 0 1 2 2 0

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A G Y E M A N G D O R O T H Y 1 2 / 0 7 / 1 9 8 1
Gender Male Female
3 1
NHIS no. 3 9 2 2
M H C 0 / 0 1 6 5 4 4

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A C H I R I D I A N A 1 3 / 0 4 / 1 9 8 1
Gender Male Female
3 1
NHIS no. 7 3 6 5 2 7 5 8
M H C 1 / 0 2 4 7 0 5

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Specialty Description: P O S T
N A T A L
C L I N I C
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O W U S U J O Y C E 2 5 / 0 3 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 7 3 2 6 2 6 1 6
M H C 0 / 0 2 7 5 9 0

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K A N T O N E L I Z A B E T H 0 6 / 0 6 / 1 9 8 0
Gender Male Female
3 2
NHIS no. 4 3 4 7 8 9 8 0
M H B 8 / 0 0 6 7 5 4

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O D O N K O R M A V I S 1 9 / 0 5 / 1 9 7 1
Gender Male Female
4 1
NHIS no. 7 3 6 2 7 0 2 4
M H B 0 / 0 1 5 7 3 8

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M O H A M M E D Z A I N A B 1 1 / 0 7 / 1 9 8 7
Gender Male Female
2 5
NHIS no. 7 3 9 2 4 1 0 3
M H C 1 / 0 2 2 7 6 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M E N S A H C Y N T H I A 1 0 / 1 2 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 2 7 3 9 3 5 8
M H C 1 / 0 1 9 4 4 5

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A W U A H R E G I N A 1 8 / 0 7 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 3 5 7 4 3 6 7
M H B 9 / 0 1 2 2 5 5

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A B A D U R I T A 2 7 / 1 0 / 1 9 8 6
Gender Male Female
2 6
NHIS no. 7 4 5 2 0 1 5 0
M H C 1 / 0 2 6 4 4 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A W O R N Y O R E B E C C A 1 5 / 0 8 / 1 9 7 6
Gender Male Female
3 6
NHIS no. 1 5 3 4 7 2 1 0
M H B 8 / 0 1 4 8 2 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Z A K A R I A D I Z A 0 1 / 0 7 / 1 9 8 7
Gender Male Female
2 5
NHIS no. 7 4 6 8 4 8 3 9
M H C 0 / 0 3 1 7 4 0

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D E H C O N S T A N C E 2 7 / 0 3 / 1 9 9 1
Gender Male Female
2 1
NHIS no. 7 5 6 3 3 8 8 4
M H B 4 / 0 2 5 0 4 6

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
N A T A L
C L I N I C
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Y E A R K C H R I S T I N A 0 7 / 0 9 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 7 1 9 0 5 3 3 3
M H C 1 / 0 2 6 6 6 7

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A M A N U E R N E S T I N A 1 2 / 0 5 / 1 9 7 5
Gender Male Female
3 7
NHIS no. 1 7 6 5 2 2 2 3
M H B 1 / 0 0 6 8 1 7

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
B A N N O R V I C T O R I A 2 7 / 0 8 / 1 9 3 7
Gender Male Female
7 5
NHIS no. 7 4 5 2 5 2 1 8
M H C 1 / 0 3 7 2 3 8

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code:
Specialty Description: S U R G I C A L
O U T P A T I E N T
D E P A R
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
Tari Amount
. 0 . 0 0 . .
Signature
Name

0 . 0 0
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O S E I S A R A H
P O K U
Gender Male Female Age
1 2 / 0 5 / 1 9 8 7
Hospital Record No
2 5
NHIS no. 7 6 0 6 4 0 5 1
M H C 1 / 0 3 1 0 7 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
B O S S M A N H I L D A 2 7 / 0 3 / 1 9 8 0
Gender Male Female
3 2
NHIS no. 4 4 2 0 1 0 6 1
M H A 9 / 0 2 1 0 5 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Specialty Description: F E M A L E
O U T P A T I E N T
D E P A R T M
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
D 2 5 . 9
G-DRG
O P D C 0 6 A
Leiomyoma of uterus, unspecified
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 6 A
Tari Amount
. 6 . 1 6 . .
Signature
Name

6 . 1 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Q U A Y E - M E N S A H E R I C 2 5 / 0 4 / 1 9 5 7
Gender Male Female
5 5
NHIS no. 7 6 0 0 6 5 2 0
M H C 2 / 0 0 2 4 8 1

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
O U T P A T I E N T
D E P A R
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
K 4 0 . 9
G-DRG
O P D C 0 6 A
Unilateral or unspecified inguina
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 6 A
Tari Amount
. 9 . 6 6 . .
Signature
Name

9 . 6 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A G B O V I E L I Z A B E T H 0 3 / 0 3 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 1 9 6 5 8 8 9
M H C 1 / 0 3 3 9 4 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
P O K U A A J A N E T 0 4 / 0 7 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 5 3 0 0 6 9 4 3
M H C 1 / 0 2 8 1 0 4

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A G B E N Y E G A H B E A T R I C E 2 1 / 0 7 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 6 0 2 8 9 2 3 0
M H B 8 / 0 1 9 4 3 4

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K O T E I C O M F O R T 2 1 / 1 2 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 7 2 9 9 3 9 5 5
M H B 5 / 0 0 7 2 7 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
2 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A M O A H V I C T O R I A 2 7 / 0 8 / 1 9 3 7
Gender Male Female
7 5
NHIS no. 7 4 5 2 5 2 1 8
M H C 1 / 0 3 7 2 3 8

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
O U T P A T I E N T
D E P A R
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 6 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 6 A
Tari Amount
. 9 . 6 6 . .
Signature
Name

9 . 6 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A T T A A H A K O S U A M A R Y
Age
Gender Male Female
0 1 / 0 4 / 1 9 7 9
Hospital Record No
3 3
NHIS no. 7 8 4 4 9 8 7 6
M H C 2 / 0 0 3 4 5 6

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Date
1 4 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 2 A
1 2 3 4 5
ICD-10
P 2 0 . 0
G-DRG
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 2 A
Tari Amount
. 1 8 5 . 7 7 . .
Signature
Name

1 8 5 . 7 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O B E N U C E P H A S T E Y E
Age
Gender Male Female
2 2 / 0 2 / 1 9 7 6
Hospital Record No
3 6
NHIS no. 5 8 9 2 8 9 7 9
M H

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code:
Specialty Description: U N B U N D L E D
S E R V I C E S
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
Date
1 4 / 0 2 / 1 2 1 4 / 0 2 / 1 2
/ / / / / /
G-DRG
I N V E S 7 5 I N V E S 2 4
Lipid Profile Bue & Creatinine
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
Tari Amount
. 0 . 0 0 1 4 . 2 0 .
Signature
Name

1 4 . 2 0
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
T A G O E A M A ( M A T I L D A ) 0 4 / 0 2 / 2 0 1 2
Hospital Record No Age < 1
Gender Male Female NHIS no. 4 8 1 8 5 1 0 8
M H C 2 / 0 0 5 0 0 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: P A E D
Specialty Description: P A E D I A T R I C S
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
A 4 1 . 4
G-DRG
P A E D 1 4 C
Septicemia due to anaerobes
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
P A E D 1 4 C
Tari Amount
1 1 7 . 2 6 . . .
Signature
Name

1 1 7 . 2 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A D J E I M A B E L 1 4 / 0 5 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 5 6 5 1 3 8 6 1
M H C 2 / 0 0 1 4 4 6

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Date
1 4 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 4 A
1 2 3 4 5
ICD-10
O 7 5 . 6
G-DRG
Delayed delivery after spontaneou
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 4 A
Tari Amount
5 6 . 1 6 . . .
Signature
Name

5 6 . 1 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
T A M A N J A F E L I C I A 2 5 / 0 9 / 1 9 8 7
Gender Male Female
2 5
NHIS no. 7 3 6 0 1 7 5 1
M H C 1 / 0 3 6 1 6 4

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
N A T A L
C L I N I C
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
T A G O E M A T I L D A 2 6 / 0 6 / 1 9 7 2
Gender Male Female
4 0
NHIS no. 4 8 1 8 5 1 0 8
M H C 2 / 0 0 2 5 9 2

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Z I L E V U P H I L I P I N E 2 0 / 1 1 / 1 9 8 3
Hospital Record No
E . Y
Age
Gender Male Female
2 9
NHIS no. 4 3 0 0 6 9 3 0
M H B 5 / 0 2 0 9 5 9

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K U M A E S T H E R 1 8 / 0 3 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 6 6 1 0 1 8 5
M H C 1 / 0 3 5 4 0 4

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Date
1 4 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 3 A
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 3 A
Tari Amount
. 4 7 . 3 2 . .
Signature
Name

4 7 . 3 2
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K U M A E S T H E R 1 8 / 0 3 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 6 6 1 0 1 8 5
M H C 1 / 0 3 5 4 0 4

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
3 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
T E T T E H G A H R E B E C C A 2 3 / 0 7 / 1 9 8 0
Gender Male Female
3 2
NHIS no. 7 4 1 7 6 8 9 5
M H B 4 / 0 1 8 8 6 7

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
H A Y F O R D A L I C E 2 3 / 0 4 / 1 9 8 9
Gender Male Female
2 3
NHIS no. 7 6 7 0 4 8 6 7
M H C 1 / 0 3 4 9 4 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
L E G I B O D I A N A 1 5 / 0 1 / 1 9 7 2
Gender Male Female
4 0
NHIS no. 7 7 4 7 8 3 0 1
M H A 9 / 0 1 0 0 9 7

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Date
1 4 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 2 A
1 2 3 4 5
ICD-10
P 2 0 . 0
G-DRG
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 2 A
Tari Amount
1 8 5 . 7 7 . . .
Signature
Name

1 8 5 . 7 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A W U D U Z A L I Y A 0 6 / 0 2 / 1 9 7 3
Gender Male Female
3 9
NHIS no. 1 5 2 5 9 8 1 6
M H C 1 / 0 3 7 4 2 2

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A M P A W G L O R I A 2 5 / 0 6 / 1 9 7 4
Gender Male Female
3 8
NHIS no. 7 6 9 1 9 9 4 9
M H A 9 / 0 0 5 9 1 3

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D A G B A N A R E B E C C A 1 2 / 1 2 / 1 9 8 6
Gender Male Female
2 6
NHIS no. 1 0 0 6 6 9 1 6 7
M H B 1 / 0 0 9 8 2 1

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K O F F I E D E L A L I C E L E S T I N E
Age
Gender Male Female
0 3 / 0 6 / 1 9 8 2
Hospital Record No
3 0
NHIS no. 5 9 0 3 7 1 7 1
M H B 9 / 0 2 4 2 8 2

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
I S A T S U P R I N C I L L A 3 0 / 1 1 / 1 9 9 0
Gender Male Female
2 2
NHIS no. 7 8 6 7 4 7 0 2
M H C 2 / 0 0 4 0 5 0

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Q U A R S H I E L Y D I A M I L L S
Age
Gender Male Female
1 2 / 1 1 / 1 9 8 0
Hospital Record No
3 2
NHIS no. 7 7 7 3 7 2 4 7
M H B 7 / 0 2 3 5 9 2

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A G Y E I G R A C E 0 4 / 0 6 / 1 9 7 4
Gender Male Female
3 8
NHIS no. 7 8 8 1 5 2 8 3
M H A 9 / 0 1 7 2 4 8

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
4 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
N K R U M A H H O L I E V E 1 6 / 0 8 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 1 2 6 3
M H B 5 / 0 2 7 3 8 8

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Q U I S T C A T H E R I N E 0 4 / 0 7 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 1 9 5 9 5 7 6 3
M H B 6 / 0 0 7 4 5 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 6 / 0 1 / 2 0 1 2
/ / / /
Duration(days)
- 3 0
Date
1 5 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 3 A
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 3 A
Tari Amount
4 7 . 3 2 . . .
Signature
Name

4 7 . 3 2
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A B B E Y A G N E S 1 9 / 0 8 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 4 2 9 2 8 4 6 4
M H B 7 / 0 1 7 2 3 8

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A N A B I L A E M E L I A 2 4 / 0 6 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 1 5 3 3 2 3 6 1
M H B 9 / 0 1 0 3 9 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
N A T A L
C L I N I C
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K P O D O I V Y 2 5 / 0 4 / 1 9 8 6
Gender Male Female
2 6
NHIS no. 7 1 7 9 5 6 4 9
M H B 9 / 0 1 2 7 2 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A R H I N S A H A G N E S 1 5 / 0 6 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 3 1 9 1
M H B 6 / 0 1 2 9 0 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
W I R E D U V E R O N I C A 0 3 / 1 0 / 1 9 8 3
Gender Male Female
2 9
NHIS no. A M C 0 0 6 1
M H B 6 / 0 2 1 4 8 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
N A T A L
C L I N I C
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A H E D O R H O P E A N T H O N Y
Age
Gender Male Female
2 9 / 0 3 / 1 9 8 3
Hospital Record No
2 9
NHIS no. 4 2 3 9 7 6 2 1
M H B 5 / 0 1 7 4 7 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: A S U R
Operations on the Ureth
Date
1 5 / 0 2 / 2 0 1 2
/ / / /
G-DRG
A S U R 2 1 A
1 2 3 4 5
ICD-10
N 3 4 . -
G-DRG
Urethritis and urethral syndrome
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
A S U R 2 1 A
Tari Amount
5 4 1 . 3 2 . . .
Signature
Name

5 4 1 . 3 2
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K O O M S O N T H E R E S A 2 2 / 0 2 / 1 9 8 5
Gender Male Female
2 7
NHIS no. 3 8 5 7
M H B 7 / 0 0 0 6 4 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O C L O O G L O R I A 3 0 / 0 6 / 1 9 4 1
Gender Male Female
7 1
NHIS no. 4 2 5 1 3 1 9 2
M H B 6 / 0 2 4 7 5 9

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 2 2 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: M E D I
Specialty Description: M E D I C A L
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
E 1 4 . 1
G-DRG
M E D I 0 3 A
With ketoacidosis
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
M E D I 0 3 A
Tari Amount
1 6 2 . 3 7 . . .
Signature
Name

1 6 2 . 3 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O C L O O G L O R I A 3 0 / 0 6 / 1 9 4 1
Gender Male Female
7 1
NHIS no. 4 2 5 1 3 1 9 2
M H B 6 / 0 2 4 7 5 9

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 5 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: M E D I
Specialty Description: M E D I C A L
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
E 1 4 . 1
G-DRG
M E D I 0 3 A
With ketoacidosis
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
M E D I 0 3 A
Tari Amount
2 4 3 . 8 8 . . .
Signature
Name

2 4 3 . 8 8
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A C H E A M P O N G E R N E S T I N A 0 3 / 0 7 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 4 1 3 0
M H C 0 / 0 2 5 9 2 8

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A L I Y A H A Y A 2 2 / 1 0 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 1 6 8 3 3 7 9 1
M H C 1 / 0 1 0 5 5 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Specialty Description: P O L Y C L I N I C
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
E 2 3 . 2
G-DRG
O P D C 0 6 A
Diabetes insipidus
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 6 A
Tari Amount
. 9 . 6 6 . .
Signature
Name

9 . 6 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A B U B A K A R I F A T I 0 3 / 0 5 / 1 9 8 5
Gender Male Female
2 7
NHIS no. 3 4 2 9 0 8 9 3
M H C 1 / 0 1 4 9 2 3

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O D I A M P O M A H V I D A
Age
Gender Male Female
0 1 / 0 1 / 1 9 3 5
Hospital Record No
7 7
NHIS no. 6 6 6 5 7 5 3 7
M H A 9 / 0 2 9 7 1 9

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 2 7 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
1 2
Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: A S U R
External Hernia Repair
Date
1 5 / 0 2 / 2 0 1 2
/ / / /
G-DRG
A S U R 2 0 A
1 2 3 4 5
ICD-10
K 4 0 . 0
G-DRG
Bilateral inguinal hernia, with o
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
A S U R 2 0 A
Tari Amount
1 6 8 . 8 7 . . .
Signature
Name

1 6 8 . 8 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
N O R T E Y E E D M U N D 2 1 / 0 3 / 1 9 3 2
Gender Male Female
8 0
NHIS no. 1 5 3 2 9 4 6 8
M H

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
Specialty Description: M A L E
O U T P A T I E N T
D E P A R T M E N
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
M 2 5 . 5
G-DRG
O P D C 0 6 A
Pain in joint
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 6 A
Tari Amount
. 9 . 6 6 . .
Signature
Name

9 . 6 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A S A N T E S H E R R Y 0 1 / 1 0 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 6 0 9 1 6 2 9 5
M H B 0 / 0 1 9 9 1 9

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A S A R E G I F T Y 1 4 / 0 9 / 1 9 8 6
Gender Male Female
2 6
NHIS no. A Y A 0 0 4 2 9 5
M H C 1 / 0 1 8 4 9 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Q U A Y E L Y D I A 2 7 / 0 9 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 6 8 3 0 1 4 1 6
M H C 1 / 0 0 5 6 7 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O W U S U M A R Y
S E K Y E R E
Gender Male Female
0 2 / 0 6 / 1 9 8 5
Hospital Record No
Age
2 7
NHIS no. 7 1 1 7 3 9 0 2
M H B 8 / 0 3 1 3 2 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2
/ / / /
Duration(days)
Date
1 5 / 0 2 / 2 0 1 2
/ / / /
G-DRG
O B G Y 3 4 A
1 2 3 4 5
ICD-10
O 7 5 . 6
G-DRG
Delayed delivery after spontaneou
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O B G Y 3 4 A
Tari Amount
5 6 . 1 6 . . .
Signature
Name

5 6 . 1 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
T U R K S O N S A M U E L 2 5 / 1 0 / 1 9 6 5
Gender Male Female
4 7
NHIS no. 5 8 9 2 5 7 2 1
M H C 1 / 0 2 5 3 6 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
O U T P A T I E N T
D E P A R
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
T 1 4 . 9
G-DRG
O P D C 0 6 A
Crush Injury
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 6 A
Tari Amount
. 9 . 6 6 . .
Signature
Name

9 . 6 6
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
7 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M U D O R V I C T O R I A 1 3 / 0 2 / 1 9 8 1
Gender Male Female
3 1
NHIS no. 2 3 6 9
M H B 7 / 0 1 0 0 3 8

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
7 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
H A M M O N D V I D A 2 5 / 0 7 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 3 0 9 4
M H B 9 / 0 1 8 9 9 1

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A R H I N S A H A G N E S 1 5 / 0 6 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 3 1 9 1
M H B 6 / 0 1 2 9 0 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
5 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K O O M S O N T H E R E S A 2 2 / 0 2 / 1 9 8 5
Gender Male Female
2 7
NHIS no. 3 8 5 7
M H B 7 / 0 0 0 6 4 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A C H E A M P O N G E R N E S T I N A 0 3 / 0 7 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 4 1 3 0
M H C 0 / 0 2 5 9 2 8

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A B U B A K A R I F A T I 0 3 / 0 5 / 1 9 8 5
Gender Male Female
2 7
NHIS no. 3 4 2 9 0 8 9 3
M H C 1 / 0 1 4 9 2 3

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A S A N T E S H E R R Y 0 1 / 1 0 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 6 0 9 1 6 2 9 5
M H B 0 / 0 1 9 9 1 9

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A S A R E G I F T Y 1 4 / 0 9 / 1 9 8 6
Gender Male Female
2 6
NHIS no. A Y A 0 0 4 2 9 5
M H C 1 / 0 1 8 4 9 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
6 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Q U A Y E L Y D I A 2 7 / 0 9 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 6 8 3 0 1 4 1 6
M H C 1 / 0 0 5 6 7 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
7 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O T O O E L I Z A B E T H 1 9 / 0 2 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 2 9 5 2 2 1 9
M H C 1 / 0 2 1 8 8 9

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O B U O B I T H E R E S A 0 4 / 0 6 / 1 9 8 3
Gender Male Female
2 9
NHIS no. A Y A 0 0 4 4 8 5
M H B 7 / 0 3 4 2 8 0

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A R T H U R R E G I N A 1 0 / 0 1 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 5 6 4 9 0 1 8 2
M H C 1 / 0 0 0 6 8 1

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M I N N E A U X M A T I L D A 0 5 / 1 2 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 6 2 4 3 9 0 5 5
M H C 1 / 0 1 4 6 3 2

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A W U K U A F I A 0 5 / 0 4 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 7 2 5 1 2 5 7 5
M H A 9 / 0 1 5 1 4 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A D A D E V O H A G N E S 0 2 / 0 7 / 1 9 8 5
Gender Male Female
2 7
NHIS no. 7 3 3 7 8 8 8 2
M H C 1 / 0 1 3 4 7 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O B E N G J O Y C E 2 7 / 0 9 / 1 9 8 1
Gender Male Female
3 1
NHIS no. 7 3 4 0 7 3 9 1
M H C 1 / 0 2 1 3 4 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D O R V I C O M F O R T 0 5 / 0 9 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 5 7 3 2 5 2 5 5
M H B 7 / 0 1 7 9 4 1

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
I C I B U D E B O R A 2 5 / 0 3 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 7 3 4 8 3 1 0 4
M H C 1 / 0 2 0 6 7 0

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Y A W S O N R E B E C C A 2 8 / 0 8 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 7 3 2 3 8 4 0 8
M H B 8 / 0 2 5 1 0 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
8 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
B O T C H W A Y F L O R E N C E 2 3 / 1 1 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 7 4 1 8 3 1 7 4
M H C 1 / 0 2 6 9 4 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O T E N G G E R T R U D E 2 5 / 0 9 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 7 3 9 2 1 9 8 8
M H C 1 / 0 1 4 1 7 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A M E D E K A R E G I N A 0 1 / 0 8 / 1 9 8 1
Gender Male Female
3 1
NHIS no. 7 3 1 0 4 4 7 2
M H C 1 / 0 2 1 8 7 8

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
E S S I N E R O S E M O N D 2 9 / 1 1 / 1 9 8 0
Gender Male Female
3 2
NHIS no. 5 7 8 3 0 4 8 3
M H C 1 / 0 1 8 9 6 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A S A N T E T A N I A 0 7 / 0 5 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 7 4 3 6 8 2 1 5
M H B 7 / 0 1 8 1 5 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
B A K A I P R I S C I L L A 1 2 / 1 0 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 7 4 0 7 2 1 8 1
M H C 1 / 0 2 5 0 2 2

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Y E B O A H J U L I E T 1 6 / 0 3 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 5 2 1 8 5 0 2
M H C 1 / 0 2 9 1 5 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O D A M T E Y A B I G A I L 2 5 / 1 2 / 1 9 8 7
Gender Male Female
2 5
NHIS no. 7 5 4 5 7 3 8 8
M H C 1 / 0 2 9 4 1 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A M A R T E Y B E R N I C E 1 4 / 0 5 / 1 9 7 8
Gender Male Female
3 4
NHIS no. 4 2 3 7 1 3 0 5
M H A 9 / 0 4 0 3 8 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A L H A S S A N A Y I S H A 2 5 / 0 9 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 7 5 4 6 7 4 1 0
M H C 1 / 0 3 1 4 8 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
9 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
O B E N G F E L I C I A 1 1 / 0 5 / 1 9 8 6
Gender Male Female
2 6
NHIS no. 7 4 7 2 2 7 5 3
M H C 1 / 0 2 7 3 8 2

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D O T S E Y M A R Y 2 3 / 0 6 / 1 9 8 2
Gender Male Female
3 0
NHIS no. 7 4 7 0 0 9 3 2
M H B 4 / 0 0 1 1 8 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
L A V O E E L I Z A B E T H 2 8 / 0 6 / 1 9 8 3
Gender Male Female
2 9
NHIS no. 7 5 2 8 0 3 6 8
M H B 5 / 0 2 8 0 3 2

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M A R T E Y V I D A 1 9 / 0 9 / 1 9 7 5
Gender Male Female
3 7
NHIS no. 7 4 9 3 9 2 0 4
M H B 0 / 0 0 8 3 3 1

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
S O S I R E G I N A 1 5 / 0 4 / 1 9 7 9
Gender Male Female
3 3
NHIS no. 6 4 7 0 1 7 7 7 3
M H C 1 / 0 3 2 7 0 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
K O M E S U O M A R Y 1 2 / 1 1 / 1 9 7 4
Gender Male Female
3 8
NHIS no. 7 4 0 1 2 5 9 0
M H B 0 / 0 3 6 0 4 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 5 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M O H A M M E D H A S S A N A S A L I F U
Age
Gender Male Female
0 5 / 0 5 / 1 9 8 8
Hospital Record No
2 4
NHIS no. 6 6 4 0 5 5 4 8
M H C 1 / 0 3 4 6 0 3

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 6 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
D E B R A H
A .
C H R I S T I A N A 1 6 / 0 6 / 1 9 7 5
Gender Male Female
3 7
NHIS no. 7 7 2 6 9 9 5 3
M H C 2 / 0 0 0 4 1 2

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 7 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A M P O M E V I D A 1 1 / 0 8 / 1 9 8 0
Gender Male Female
3 2
NHIS no. 7 7 6 5 4 8 8 3
M H C 2 / 0 0 1 1 9 2

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 8 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
T W U M R I T A 0 5 / 0 8 / 1 9 8 4
Gender Male Female
2 8
NHIS no. 7 6 7 2 2 4 3 6
M H C 1 / 0 3 5 2 7 6

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 0 9 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
A G B E T S I A F A D E L A L I 2 9 / 0 9 / 1 9 7 4
Gender Male Female
3 8
NHIS no. 7 7 2 0 6 3 1 1
M H B 6 / 0 1 5 5 1 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 1 0 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
N A R T E Y M E R C Y 2 3 / 0 7 / 1 9 8 7
Gender Male Female
2 5
NHIS no. 7 4 8 9 6 1 3 6
M H B 4 / 0 1 3 7 6 3

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 1 1 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
Y U S S I F H A B I B A 1 5 / 0 5 / 1 9 7 7
Gender Male Female
3 5
NHIS no. 7 4 2 8 8 1 3 7
M H C 2 / 0 0 2 4 3 7

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 1 2 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M U M U N I M O N I C A 0 7 / 1 2 / 1 9 7 3
Gender Male Female
3 9
NHIS no. 7 8 4 7 8 0 7 1
M H C 1 / 0 3 4 1 4 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 1 3 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M U M U N A F A R I D A 2 9 / 0 9 / 1 9 8 0
Gender Male Female
3 2
NHIS no. 7 8 0 1 7 8 0 4
M H C 1 / 0 3 4 9 9 4

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
G-DRG
O P D C 0 2 A
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Claim Form
A Y A W A S O
S U B - M E T R O
1 1 4 Date of Claim 0 4 / 0 4 / 2 0 1 2
Client Information
M U D O R V I C T O R I A 1 3 / 0 4 / 1 9 8 1
Gender Male Female
3 1
NHIS no. 7 7 6 3 1 2 6 7
M H B 7 / 0 1 0 0 3 5

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /
Duration(days)
/ / / / / /
G-DRG
1 2 3 4 5
ICD-10
O 8 0 . 9
G-DRG
O P D C 0 2 A
Normal Pregnancy
Date
/ / / / / / / / / /
G-DRG
. . . . .
Qty
Total Cost
. . . . .
Code

G-DRG/Code
O P D C 0 2 A
Tari Amount
. 1 3 . 2 7 . .
Signature
Name

1 3 . 2 7
Date Date
Signed Signed

Aya 11 15

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NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y

Intrauterine hypoxia first noted

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Client Claim Summary Type of Service

(Health Facility Insurance Ocer)

TOTAL Scheme Use Only

NATIONAL HEALTH INSURANCE SCHEME

Gender Male Female

Services Provided (to be lled by all health care providers)

Absconded/Discharged against medical advice

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C