REFERRAL FORM FOR OVERSEAS TREATMENT
MANAGED SCHEME

 

NATIONAL HOSPITAL INSURANCE FUND
P.O. Box 30443 – 00100, NAIROBI
Tel 020 – 2723255/6
Website: www.nhif.or.ke Email: info@nhif.or.ke
REFERRAL FORM FOR OVERSEAS TREATMENT
MANAGED SCHEME
Part A: Patient particulars (To be completed by the Principle member)
Name of the Principle Member: NHIF No: ID No: Job Group:
Physical Address: Tel. No:
Ministry: Work Station:
County:
Name of the Patient: Age:
Sex: (Male/Female)
Relationship of the Principle
Member:
(Self/Spouse/Dependant)
Part B: Details of the illness and planned management (To be completed by referring physician (or
equivalent) practicing in a heath facility accredited to NHIF)
Nature of the disease
How long have you treatment/managed the
patient?
Treatment/Procedure/Investigation for which
patient is being referred
Is the treatment/procedure/investigation
option available in Kenya?
If not, state why the
treatment/procedure/investigation outside
the country is necessary and essential to the
Prognosis of patient’s condition.
Part C: Undertaking By Principle Member
I fully understand the rules governing the medical benefits extended to the Civil Servants and
Disciplined Services Principle Members as provided by National Hospital Insurance Fund
(NHIF). I undertake to settle the bills pertaining to the treatment imparted by the
empanelled medical institution, in the event, I am not eligible to the medical benefit in any
way including limits owing to my job group.
SIGNATURE OF THE PRINCIPLE MEMBER: ……………………………………………
Date: ……………………………..
__________________________________________________________________________________________________________
Part D: Undertaking By Physician In charge
All the above particulars furnished are true/correct. The Principle Member has signed the
undertaking before me. The Principle Member is eligible to receive medical benefit under the
Civil Servants and Disciplined Services Scheme and NHIF Rules.
Name of the Physician/Specialist …………………………………………… Reg. No: ………………….
Hospital Stamp
SIGNATURE: …………………………..
Date: ……………………………

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