NHIF Outpatient Claim Form Free PDF Download

Here is the NHIF Outpatient Claim Form Free PDF Download for members. Download and fill the form correctly. Get the form below.

DETAILS ON THE NHIF OUT-PATIENT CLAIM FORM

Notification Number: ………………………………………..

OUT-PATIENT CLAIM FORM

This form is designed to be completed in sections. All fields are relevant and MUST be completed to enable processing.

 Ensure member validity and account is valid and up to date.
 Every visit must be notified within 24 hours and the generated notification number indicated on the form.
 Payments are contingent upon validity at the time of service and providers shall be responsible for
ascertaining beneficiary eligibility.
 Claims not notified shall not be reimbursed neither shall unduly filled forms be processed.
 Ensure that the invoice, pre-authorization form and the other necessary claim form requirements are attached before submission.

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PART 1: PATIENT INFORMATION

To be filled by the Patient

Surname: Other Names:
Members’ ID No: Member NHIF No:
Relationship: Principal Member: Spouse: Child: Gender:- Male: Female:
Date of Birth: DD/MM/YEAR Patients’ Phone No:
I certify that the above information is correct. I understand that it is an offence to knowingly make any false
statement for purposes of obtaining any benefit under NHIF Act.

Name:_____________________________________ Signature: _______________________________ Date: ______________________________

PART 2: HOSPITAL PARTICULARS

To be filled by the Hospital Representative
Facility Name: Facility Code:
Outpatient No. (OP/No): Scheme Type: National Managed

PART 3: NATURE OF TREATMENT

To be filled by Clinician, Specialist/Consultant at the health facility.
In cases where patient has been referred you are required to attach the copy of certified referral letter.
Reason for Visit:
New Visit Scheduled Follow- Up Visit (Clinics) Repeat Visit (Unscheduled) Referral Emergency
Treatment Condition:
Acute Acute on Chronic Chronic Maternity Surgical Congenital
Treatment Outcomes: ( Tick as appropriate)
Allowed home on treatment
Admitted
Referred

Resolved
Absconded
Deceased
Clinician’s/Specialist Names: Registration No:

PART 4: TREATMENT AUTHENTICATION

To be filled by the Hospital Representative
Patients’ Date of Attendance (DOA)……………….. Check in Time…………………… Check out Time………………………..
Primary Diagnosis: ICD 10 code:
Secondary Diagnoses:
ICD 10 code (s):
Procedure Code: Date of Service:
Pre-Authorization Reference Number (Where Applicable):
Services Description (Procedure/Service/Supplies Issued) Cost
Consultation
Laboratory
Pharmacy
Imaging
Surgery
Outpatient procedures
TOTAL COST

HOSPITAL REPRESENTATIVE: I declare that to the best of my knowledge the foregoing statements are true in every respect. I understand that it is an offence to knowingly make any false statement for purposes of obtaining any benefit
under NHIF Act.
Signature: __________________________________ Date: __________________________________

PART 5: PATIENT’S AUTHENTICATION

I certify that I have received the above treatment at the cost of Kshs ………………….. and that the above information is
correct. I understand that it is an offence to falsify information for purposes of obtaining any benefit under NHIF Act.
Nadhibitisha ya kuwa matibabu niliyo yapokea ni ya kadri shillingi ……………… za Kenya na kwamba habari niliyo andika
katika fomu hii ni sahihii. Naelewa kwamba ni kosa kuandika uongo kwa madhumuni ya kupata faida kulingana na
kitendo cha sheria ya shirika la kitaifa ya bima ya afya.
Names (Majina):________________________________________________________________________________________________________________
Signature (Sahihi): _______________________________ Date (Tarehe): _______________________________________
NOTE
 Please be advised that reimbursement is based upon agreed terms and the medical information provided. If
services, providers or dates of services change from these indicated, NHIF must be contacted/notified prior to
services being rendered.
 Payment for services rendered is subject to verification of outcomes of care and beneficiary eligibility as at
the date of service provision. Contractual obligations with the provider take precedence.
Facility stamp

Click here to download the PDF form.