Qo. : vale og =e | Mepicat ADMINISTRATOR - Ras # a Kenya Listen HOSPITAL DETAILS" NYsC WOOO 5064620 Hospital/ProviderName: Tike WARE CRESCENT HOSPITAL. Hospital/Provider Address: MEMBER PARTICULARS ‘Scheme Name: 6 C, Member Sumame: TER OAD Member Other Names! “ERCP Name of Patient Not The Same As Employes: AGREE LET TENA Relationship to Employee: Self] spouse sonO CaushterO Date of sith HR REOEGR Member Na, 52 59.36 Bank Account Number NHIF No. Bank Name: National ID No. 2-2 Gur} 202 - Bank Branch THE WHITE CRESCEN | Telephone No(s) & Email address: OA QOBI3SAR, HOShITAl ‘TREATMENT DETAILS (To be completed by attending doctor) 15 MAR 2022 ) Diagnosis Please 7 8.0. Box (320-3002) f i) Is this a post hospitalization visi? LILA yes please indicate when member wes hospitalized IO OI OIOIOIO ili) ls the condition work related or an occupational illness TIL™ ifs please explain iv) When was the condition frst diagnosed? ie ep nea ofthe ilinasstes)? ils the condition key to recur? ZEW. the condition congenital? CIEL wicinial summon Soutr (ae zyod 7 oie, kf cedle, ance Dla g panang, IB, AD Cedsh vip Department [245 cal at CORR ek en vil) Sub Department. 0 pate nk WORK/OCCUPATIONAL ILLNESS OR INJURY 1} Date of Accident OO BO OOOO i Cause of Accident Time of Accident Place of Occurence iil Patient's date of admission DOOD DONO Patients dete of discharge OODOO000 Note: Please attach a copy of Police Abstract Thereby certify that al the answers and all documents submitted vith this claim form are complete and true. I hereby authorize any doctor, hospital, clinic or other organization that has information about me or my dependants to provide the Medical Scheme Administrators and/ or insurers with complete information and records of treatment, findings otc + | Patient / Parent / Guardian Signature. + date BOBOOOO0 : : {erty tat the above treatment was administered by me tothe eat gf wes carried aut at my instruction by other practitioners » ovestabiishments. = aa ae eager fallen fame Spore et Bia 7 FST Marika Rood, reign “@ ane a ae > Tare MARS Wao a AO