NHIF Registration Form

APPENDIX1

NOT FOR SALE

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

NATIONAL HOSPITAL INSURANCE FUND

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:

Attach Copies of National Identity Card/Alien ID/Passport for both the contributor and spouse where
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)
For new registration of employed persons attach an introduction letter or have the form stamped by the
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:

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.
Toaccess beneﬁts one MUST be a duly registered member and must have declared their
To choose an Out patient facility,attach a copy of the contributor’s National

	NAME	Date of Birth			Gender	Preferred Medical Facility
	NAME	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:

……………………………………………………………..

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

……………………………………………………………..

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

……………………………………………………………..

PART V: CHANGE OF OUTPATIENT HEALTH FACILITY

Guidelines:

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

Receiving Officer ………………………………………………………………………………………………….. Sign ………………………………..Date ……………………………….
Data Capture Officer ……………………………………………………………………………………………. Sign ………………………………. Date ……………………………….
Approving Officer …………………………………………………………………………………………… Sign ………………………………. Date ……………………………….

NHIF Registration Form

ByHillary Kangwana

NHIF Registration Form

APPENDIX1

NOT FOR SALE

REGISTRATION FORM

By Hillary Kangwana

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