IT@iF NHrF Bd/6-7-1'5

,Revisedi2tla-o,

SU RG'fl AL ST PYI {TT PP} fl . &i"JT}.{O&ITATION FCIRM

PLEASE BE A5 COMPREHENSIVE AND ACCURA1E A5 POSSIBLE WHEN COMPI FTINO ft!15 FORM- ERRORS OR OMMISSIONS MAY OELAY APPROVAL.

SECTION r: PATIENT INFORMATION (To be Jilted by the Patient/Guardian)

Surname: Other Names: Countyi

Patient's lD No/Birth Cert./ Patient's

NHIF Member No:
Notification No: Phone No:

Principal Member Phone No: '

lf patient is below:.8 years, Name of Guardian: Relationship to patient:

Do you have any other MEDICAL insurance cover? Yes ! No Li lf YES, qive details:
I !

PATIENT OR AUTHORISED PERSON'S DECLARATTON: I certify that the above information is correct and give specific consent for
surgery to be done. I understand that it is an offence to knowingly make any false statement for purposes of obtaining any ben'efit
under NHIF Act.

Signature: Date:
SECTION z: HOSPITAL INFORMATION --
Hospital Name: Hospita I Representative I nformation

Hospital Cocle: Facility Level: Nanrr:

Phone No: ld No: Desiqnation:

ProvisionalDiagnosis: :'.lifFl}:li:::!i:ai:ii.,,:,:
-", .,#;: "

lsthe member Co-insured (chec,k)i. 'Yes tr;iNo tr .,{

r,ill ' !i irl::.-'rl
- i i

The Be neficiary is eligible for thii:benr6fit: :',': ,'

,1,,1r:' : ii(ost of proced ure$(Attach ffo-forma inyoice)
': ,
:, . ,ttt.
Comprehensively E Non - comprehensively U
..

HOSPITAL DECLARATION: This is to certify that to the best of my knowledge, the information"clol-rtalned.in .!hii'ldrm, and any
attachments provided is true, accurate, and complete and the roquested service(s|'is n"."rrary'tn'the health dft[e patient. I

understand that it is an offence to knowingly make any false statement for purposes of obtaining any benefit under NHtF AcU

Signature: Date: _-

SECTION :: PRACTITIONER'5 DECLARATION-SURGEON ,-::! : . !,r

t-: . ,jr, I

Surgical Procedure requested for: Protedure Code

Clinical lndication for the precedure: ls the oatient's conditibn ielated to:
.:
a. Employment: Yes fl. No tr

b, Auto orpther Atcident: Yes [J \O tr

-.:t.-

Nar"e, -- -f i*g".kp eciality: :4r

l(MPDC Reg. No: lD No: Fhone No:

I
't

r'i. l

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 NHiF NHrF Bd/6-7-1s

Revised 2020

PRACTITIONER DECLARATION: Th is is to <.ertify that the in lerrd erl sLr r c,;ir a1 procedure is rightly indicated for the presenting condition
r:f the beneficiary and the desired outcome shall be of valuo in ,n;rnaqilrl tl'ro c ondition. Attached is evidence supporting the decision
to perform the operation followinq review by nryself.

(tict< as appropriate) Radiological exam: E Labi;ratory tr:sts, i LaSO >umn )ary: L l

-1

SECTION 4: PRACTITIONERS DECLARATION-ANAESTHESI ST

Surgical Procedure requested for

Scheduled Date:

Type of anaesthesia Is the patient's condition related to:

General anaesthesia D Spinal Block n a. Employment: Yes ! No tr

Local Anaesthesia Ll Sedation ll b, Auto orotherAccident: Yes tr No tr
:,tr"(laltty

l(MPDC Reg. No lD No

PRACTITIONER DECLARATION: This is to certify that the anaesthesia nrethod selected is appropriate for the presenting condition
of the benef iciary contingent to review by myself : Signature: .................... Date:.............

Notice: Any person/institution wholwhich knowinglyfi!es a stat€ment of request or claim containing any misrepresentation or false,
incomplete, or misleading information may,Ueguihy of mdbicalfraud punishable under law or as perthe statutes of NHIF operation.

* AII ficlds in this form are mandatory and MUST be ( omiriern(l to infoirl pre-authorization decision.
* Clinicaljustification and results of preliminary diaqnostic cx,.rnrinations, where necessary, shall accompany the request.
* Payment for services rendered is subject to verification of outconres of care and beneficiary eligibility as at the date of
service provision. Contractual obliqations with the provrder t,]ke rrrr::cedence.

* Medical co-insurance declaration is Mandatory, f;rilurr to urhiclr approval will be withheld or monies recovered in case of
falsification to obtain bcne[its

* PATIENTORAUTHORISEDPERSON'SDECLARATION: ilrr,,,:rrl,rr,rtronprovidesthatthePrincipal rnemberandbeneficiary

be utilized for medical insurance purposes.

* HOSPITAL DECLARATION: This declaration provides that the hospital is declared and contracted, and is operationalunderthe

provisions on location, hospital code and contracted services. lt also provides that the member/beneficiary is eligible for access

to the contlacted benefits as per the clauses on "OBLIGATION5 OF THE HEALTH FACILITY", and the terms of engagement. lt

also provides that the hospital has taken due diligen<.e to identiiy the beneficiary and provided necessary details on the eligible

benefits and financial liability.

* PRACTITIONER DECLARATION: The listed bencficiary has prosented to the practitioner for clinical rnanagement and that the

practitioner is duly qualified and registered by the relevant authority in Kenya,

'r THEATRE LIST: All surgical requests must have an attoched theatre Lrst