NHIF change of facility, hospital form

APPENDIX3

NHIF 38

ISSUE No. 2

NATIONAL HOSPITAL INSURANCE FUND

P .O. BOX 30443 – 00100 NAIROBI, KENYA.

E-Mail: [email protected]

Website: www.nhif.or.ke

CHOICE OF OUTPATIENT MEDICAL FACILITY FORM

Guidelines:

 

1. Principal Members are required to forward a duly completed form to the nearest NHIF
2. To select a medical facility, please refer to the list of NHIF accredited health facilities available on the NHIF Website and NHIF offices
3. To access benefits one MUST be duly registered by filling NHIF Registration Form (NHIF 2) and declare their
4. A copy of the Principal Member’s National ID MUST be

 

1. PRINCIPAL MEMBER’S DETAILS

SURNAME: …………………………………….. OTHER NAMES: ………………………………………

NHIF NO. (Mandatory) ………………………… I.D NO.(Mandatory) ………………………………….

PERSONAL NO ………………………………… JOB GROUP ………………………………………….

DATE OF BIRTH (DD/MM/YYYY)……………….. GENDER (Male/Female)……………………………..

MOBILE NO: …………………………………… EMAIL ADDRESS ………………………………………

EMPLOYER …………………………………….. STATION ……………………………………………..

 

1. DEPENDANT(S)’ DETAILS

 

	NAME	DATE OF BIRTH			GENDER	PREFERRED MEDICAL FACILITY
		DD	MM	YR	M/F	CODE	NAME
PRINCIPAL
SPOUSE
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5

 

1. REASON FOR CHANGE OF FACILITY

 

Tick as applicable:

 

01	Transferred to a new workstation
02	Promotion
03	Unavailability of services for 24 hours
04	Asked to buy prescribed drugs
05	Unavailability of dental services
06	Unavailability of optical services
07	Lack of specialized services
08	Lack of laboratory services
09	Bad attitude from clinic staff
10	Current facility stopped offering services
11	Other (Specify)

 

 

1. CERTIFICATION

 

I certify that the information provided is correct to the best of my knowledge.

 

Name of Employee………………………………Signature……………………….Date………………..

 

1. FOR OFFICIAL USE

 

RECEIVED BY………………………………….Signature……………………….Date…………………..

 

UPDATED BY……………………………………Signature……………………….Date………………….

 

APPROVED BY…………………………………Signature……………………….Date………………….