REFERRAL FORM FOR OVERSEAS TREATMENT (NATIONAL 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
(NATIONAL SCHEME)
Part A: Patient particulars (To be completed by the Principle member)
Name of the Principle Member: NHIF No: ID No/Passport No:
Physical Address/Email address:
P.O Box :
Town:
Tel. No:
Employer (where applicable) Job Group(Where applicable)

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
specialist/Physician (or equivalent)
Nature of the disease
How long have you treated/managed the
patient?
Treatment/Procedure/Investigation for which
patient is being referred:
Is the treatment/procedure/investigation
option available in Kenya?
If yes, state why the
treatment/procedure/investigation outside
the country is necessary and essential to the
prognosis of patient’s condition.
2
Part C: Undertaking By Principle Member
I hereby declare that the information given above is true to the best of my knowledge and
belief. I fully understand the rules governing the medical benefits extended to the National
Scheme Members as provided by National Hospital Insurance Fund(NHIF).
SIGNATURE OF THE PRINCIPLE MEMBER: ……………………………………………
Date: ……………………………..
__________________________________________________________________________________________________________
Part D: Undertaking By Physician In charge
All the above particulars furnished are true/correct. The Member has signed the undertaking
before me.
Name of the Physician/Specialist …………………………………………… Reg. No: ………………….
Hospital Stamp
SIGNATURE: …………………………..
Date: ……………………………

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