NHIF Registration Form

APPENDIX1

NOT FOR SALE

NHIF 2 (Revised 2015 ) Folio No: ………………………

 

NATIONAL HOSPITAL INSURANCE FUND

1. P. O. Box 30443 – 00100, NAIROBI, KENYA Website: nhif.or.ke Email: [email protected]

REGISTRATION FORM

 

 

Tick where applicable

Employed

Self Employed

Organized Groups

Sponsored

 

 

 

Tick service required

Registration

Choice/Change facility

 

 

Guidelines:

1. Attach Copies of National Identity Card/Alien ID/Passport for both the contributor and spouse where
2. Please attach a copy of Birth Certificate for each For children under six (6) months, a birth notification is acceptable (only for members declaring their dependants for the first time)
3. For new registration of employed persons attach an introduction letter or have the form stamped by the
4. For change/choice of medical facility please fill PART III

PART I: MEMBER DETAILS

Surname:………………………………………………………………………………….Other Names:………………………………………………………………………………………

 

NHIF No:……………………………………….National ID /Passport /Alien I.D No.:…………………………………………………………………………………..

 

Date of Birth (DD/MM/YYYY)………………………………………………… Gender (Male/ Female):……………………………………………………….

 

Employer/Organized Group Code:…………………………………………….. Sponsor Code..:………………………………………………………………….

 

Mobile No..:……………………………………………………………………..E. mail Address.:…………………………………………………………………………………………..

 

Place of Residence (county)………………………………………………………………………….sub county……………………………………………………………

 

Postal Address:…………………………………………………………………………………. Postal Code:…………………………………………………………………………..

 

 

PART II: SPOUSE DETAILS

 

Surname:………………………………………………………….. Other Names:……………………………………………………………………………………………………………..

 

National I.D./Passport/Alien I.D. No.:………………………………….. Date of Birth (DD/MM/YYYY)   ……………………………………….

 

Gender (Male/Female):…………………………………………………….. Mobile Phone No:……………………………………………………………………………

 

PART III:  CHILDREN DETAILS AND CHOICE/ CHANGE OF FACILITY

 

Guidelines:

1. To choose an outpatient medical facility, please refer to the list of our accredited outpatient health facilities available in the H.I.F Website and Offices countrywide.
2. Toaccess benefits one MUST be a duly registered member and must have declared their
3. To choose an Out patient facility,attach a copy of the contributor’s National

 

 

 

	NAME	Date of Birth			Gender	Preferred Medical Facility
		DD	MM	YYYY	M/F	Code	Name
PRINCIPAL
SPOUCE
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5
CHILD 6
CHILD 7
CHILD 8
CHILD 9
CHILD 10

 

PART IV: PHOTOGRAPHS

Please attach one coloured passport size photo for each of the persons named in part I, II and III. Indicate the name of the person and contributor’s I.D. Number at the back of the individ.ual passport size photo(Applicable to members/ dependants whose photos do not appear in NHIF System).

 

 

Contributor’s Name:           Spouse’s Name:               Child’s Name:                  Child’s Name:

 

 

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Child’s Name:                  Child’s Name:                  Child’s Name:                  Child’s Name:

 

 

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Child’s Name:                  Child’s Name:                  Child’s Name:                  Child’s Name:

 

 

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PART V: CHANGE OF OUTPATIENT HEALTH FACILITY

 

Guidelines:

1. Please tick in the table below reasons of change where

 

01	Transferred to a new workstation
02	Unavailability of 24 hours service
03	Requested to buy prescribed drugs
04	Unavailability of dental services (if applicable)
05	Unavailability of optical services (if applicable)
06	Lack of specialized services
07	Bad attitude from clinic staff
08	Current facility stopped offering services
09	Other reasons (please specify)

 

PART V I: DECLARATION:

I hereby declare that the above information is correct to the best of my knowledge.

Name of Contributor……………………………………………………………………… Sign……………………………………… Date…………………………………….

FOR OFFICIAL USE ONLY  

 

1. Receiving Officer ………………………………………………………………………………………………….. Sign ………………………………..Date ……………………………….
2. Data Capture Officer ……………………………………………………………………………………………. Sign ………………………………. Date ……………………………….
3. Approving Officer …………………………………………………………………………………………… Sign ………………………………. Date ……………………………….