NHIF Choice Of Outpatient Medical Facility PDF Form

Download the NHIF Choice Of Outpatient Medical Facility PDF Form, below;

CHOICE OF OUTPATIENT MEDICAL FACILITY FORM

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

A. 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 ……………………………………………..

CLICK HERE TO DOWNLOAD THE CHOICE OF OUTPATIENT MEDICAL FACILITY FORM

B. 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

C. 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)

D. CERTIFICATION

I certify that the information provided is correct to the best of my knowledge.
Name of Employee………………………………Signature……………………….Date………………..
E. FOR OFFICIAL USE
RECEIVED BY………………………………….Signature……………………….Date…………………..
UPDATED BY……………………………………Signature……………………….Date………………….
APPROVED BY…………………………………Signature……………………….Date………………….