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

1. REASON FOR CHANGE OF FACILITY

Tick as applicable:

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………………….