NATIONAL HEALTH INSURANCE SCHEME

Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

0 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

S M I T H P R I S C I L L A 0 8 / 0 5 / 1 9 8 5
Hospital Record No Age

Gender Male Female

2 7

NHIS no. 3 8 5 8

M H C 0 / 0 1 4 9 0 0

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 1 / 0 2 / 2 0 1 2 1 2 / 0 2 / 2 0 1 2
/ / / /

Absconded/Discharged against medical advice

Duration(days)

1

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y

Specialty Description: O B S T E T R I C S - G Y N E C O L O G Y

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3
Spontaneous Vaginal Del

Date
1 1 / 0 2 / 2 0 1 2
/ / / /

G-DRG
O B G Y 3 3 A

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10
O 8 0 . 9

G-DRG

Normal Pregnancy

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O B G Y 3 3 A

Tariff Amount
4 7 . 3 2 . . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

4 7 . 3 2

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

1 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

B O A K Y E D O R I S 1 5 / 0 9 / 1 9 8 3
Hospital Record No Age

Gender Male Female

2 9

NHIS no. 1 5 3 3 1 1 7 8

M H B 4 / 0 2 8 2 8 6

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 2 / 0 2 / 2 0 1 2 1 8 / 0 2 / 2 0 1 2
/ / / /

Absconded/Discharged against medical advice

Duration(days)

6

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y

Specialty Description: O B S T E T R I C S - G Y N E C O L O G Y

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3
Caesarian Section (DIST

Date
1 2 / 0 2 / 2 0 1 2
/ / / /

G-DRG
O B G Y 3 2 A

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10
P 2 0 . 0

G-DRG

Intrauterine hypoxia first noted

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O B G Y 3 2 A

Tariff Amount
1 8 5 . 7 7 . . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 8 5 . 7 7

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

2 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

A D J E T E Y B E A T R I C E 0 1 / 0 7 / 1 9 8 4
Hospital Record No Age

Gender Male Female

2 8

NHIS no. 7 3 9 8 0 9 6 1

M H B 7 / 0 0 4 5 1 1

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /

Absconded/Discharged against medical advice

Duration(days)

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Specialty Description: A N T E - N A T A L

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /

G-DRG

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10
O 8 0 . 9

G-DRG
O P D C 0 2 A

Normal Pregnancy

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O P D C 0 2 A

Tariff Amount
. 1 3 . 2 7 . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 3 . 2 7

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

3 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

E S H U N M I L D R E D 1 9 / 0 4 / 1 9 8 4
Hospital Record No Age

Gender Male Female

2 8

NHIS no. A Y A 0 0 4 1 6 5

M H B 9 / 0 2 0 7 7 4

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2
/ / / / / /

Absconded/Discharged against medical advice

Duration(days)

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Specialty Description: A N T E - N A T A L

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /

G-DRG

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10
O 8 0 . 9

G-DRG
O P D C 0 2 A

Normal Pregnancy

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O P D C 0 2 A

Tariff Amount
. 1 3 . 2 7 . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 3 . 2 7

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D A D Z I E P H Y L L I S 1 0 / 0 1 / 1 9 8 4 Hospital Record No Age Gender Male Female 2 8 NHIS no. 5 2 0 6 7 9 8 1 M H B 9 / 0 2 3 3 1 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . . 2 7 Date Date Signed Signed . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . . 1 3 . 2 7 .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M E N S A H E R N E S T I N A 0 5 / 0 9 / 1 9 8 5 Hospital Record No Age Gender Male Female 2 7 NHIS no. 7 8 5 0 5 9 4 3 M H C 0 / 0 0 0 3 8 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Qty Total Cost . 1 3 . . . . 2 7 . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D O N K O R J U D I T H 1 4 / 0 8 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no. 7 3 4 9 3 1 0 1 M H C 0 / 0 0 1 2 2 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. . . Qty Total Cost . . 1 3 . . 2 7 Date Date Signed Signed . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

3 9 2 2 M H C 0 / 0 1 6 5 4 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A G Y E M A N G D O R O T H Y 1 2 / 0 7 / 1 9 8 1 Hospital Record No Age Gender Male Female 3 1 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 Date Date Signed Signed . . 2 7 . 1 3 . . Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A C H I R I D I A N A 1 3 / 0 4 / 1 9 8 1 Hospital Record No Age Gender Male Female 3 1 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 3 6 5 2 7 5 8 M H C 1 / 0 2 4 7 0 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 3 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: P O S T N A T A L C L I N I C Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 . . 1 3 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Qty Total Cost . . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 2 7 Date Date Signed Signed . .

7 3 2 6 2 6 1 6 M H C 0 / 0 2 7 5 9 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O W U S U J O Y C E 2 5 / 0 3 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

. 2 7 . Qty Total Cost . . . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 4 3 4 7 8 9 8 0 M H B 8 / 0 0 6 7 5 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 1 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K A N T O N E L I Z A B E T H 0 6 / 0 6 / 1 9 8 0 Hospital Record No Age Gender Male Female 3 2 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

. Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 1 3 . 2 7 Date Date Signed Signed . . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . 2 7 . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O D O N K O R M A V I S 1 9 / 0 5 / 1 9 7 1 Hospital Record No Age Gender Male Female 4 1 NHIS no. 7 3 6 2 7 0 2 4 M H B 0 / 0 1 5 7 3 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

2 7 Date Date Signed Signed . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . . 1 3 . . . . 2 7 .

7 3 9 2 4 1 0 3 M H C 1 / 0 2 2 7 6 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M O H A M M E D Z A I N A B 1 1 / 0 7 / 1 9 8 7 Hospital Record No Age Gender Male Female 2 5 NHIS no.

Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 . . . . 1 3 . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 Date Date Signed Signed .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M E N S A H C Y N T H I A 1 0 / 1 2 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 2 7 3 9 3 5 8 M H C 1 / 0 1 9 4 4 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

.Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 . . 1 3 . . Qty Total Cost . . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed .

M E T R O 1 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A W U A H R E G I N A 1 8 / 0 7 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 3 5 7 4 3 6 7 M H B 9 / 0 1 2 2 5 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 1 3 . . . . . 2 7 Date Date Signed Signed . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A B A D U R I T A 2 7 / 1 0 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 4 5 2 0 1 5 0 M H C 1 / 0 2 6 4 4 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . Qty Total Cost . 2 7 Date Date Signed Signed .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 1 3 .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A W O R N Y O R E B E C C A 1 5 / 0 8 / 1 9 7 6 Hospital Record No Age Gender Male Female 3 6 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 1 5 3 4 7 2 1 0 M H B 8 / 0 1 4 8 2 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. . . . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 Date Date Signed Signed . . 1 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .

7 4 6 8 4 8 3 9 M H C 0 / 0 3 1 7 4 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Z A K A R I A D I Z A 0 1 / 0 7 / 1 9 8 7 Hospital Record No Age Gender Male Female 2 5 NHIS no.

Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . . 2 7 Date Date Signed Signed . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 1 3 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . 2 7 . . .

7 5 6 3 3 8 8 4 M H B 4 / 0 2 5 0 4 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: P O S T N A T A L C L I N I C Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D E H C O N S T A N C E 2 7 / 0 3 / 1 9 9 1 Hospital Record No Age Gender Male Female 2 1 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . . . 2 7 Date Date Signed Signed . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 1 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 1 9 0 5 3 3 3 M H C 1 / 0 2 6 6 6 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Y E A R K C H R I S T I N A 0 7 / 0 9 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no.

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Qty Total Cost . 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . 2 7 Date Date Signed Signed . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . 2 7 .

M E T R O 2 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A M A N U E R N E S T I N A 1 2 / 0 5 / 1 9 7 5 Hospital Record No Age Gender Male Female 3 7 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 1 7 6 5 2 2 2 3 M H B 1 / 0 0 6 8 1 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

2 7 Date Date Signed Signed . . . 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Qty Total Cost . . . 2 7 .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 2 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth B A N N O R V I C T O R I A 2 7 / 0 8 / 1 9 3 7 Hospital Record No Age Gender Male Female 7 5 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 4 5 2 5 2 1 8 M H C 1 / 0 3 7 2 3 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: Specialty Description: S U R G I C A L O U T P A T I E N T D E P A R Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code Tariff Amount . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 0 . 0 . . Qty Total Cost . . . . 0 0 . . . 0 0 Date Date Signed Signed . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 6 0 6 4 0 5 1 M H C 1 / 0 3 1 0 7 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 2 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O S E I S A R A H P O K U Gender Male Female Age 1 2 / 0 5 / 1 9 8 7 Hospital Record No 2 5 NHIS no.

. 2 7 . . . 2 7 Date Date Signed Signed . . Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 1 3 . . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

M E T R O 2 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth B O S S M A N H I L D A 2 7 / 0 3 / 1 9 8 0 Hospital Record No Age Gender Male Female 3 2 NHIS no. 4 4 2 0 1 0 6 1 M H A 9 / 0 2 1 0 5 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: F E M A L E O U T P A T I E N T D E P A R T M Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 6 A Tariff Amount . 6 . . . unspecified Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 D 2 5 . 1 6 Date Date Signed Signed . . 1 6 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 6 . . . . . 9 G-DRG O P D C 0 6 A Leiomyoma of uterus.

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 6 0 0 6 5 2 0 M H C 2 / 0 0 2 4 8 1 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: S U R G I C A L O U T P A T I E N T D E P A R Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E N S A H E R I C 2 5 / 0 4 / 1 9 5 7 Hospital Record No Age Gender Male Female 5 5 NHIS no.M E T R O 2 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Q U A Y E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 6 A Tariff Amount . 6 6 Date Date Signed Signed . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 9 . 9 . 9 G-DRG O P D C 0 6 A Unilateral or unspecified inguina Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 K 4 0 . . . . . 6 6 .

M E T R O 2 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A G B O V I E L I Z A B E T H 0 3 / 0 3 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 1 9 6 5 8 8 9 M H C 1 / 0 3 3 9 4 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

1 3 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . . . 2 7 . . . 2 7 Date Date Signed Signed . Qty Total Cost . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

2 6 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

P O K U A A J A N E T 0 4 / 0 7 / 1 9 7 9
Hospital Record No Age

Gender Male Female

3 3

NHIS no. 5 3 0 0 6 9 4 3

M H C 1 / 0 2 8 1 0 4

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /

Absconded/Discharged against medical advice

Duration(days)

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Specialty Description: A N T E - N A T A L

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /

G-DRG

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10

G-DRG
O P D C 0 2 A

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O P D C 0 2 A

Tariff Amount
. 1 3 . 2 7 . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 3 . 2 7

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

2 7 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

A G B E N Y E G A H B E A T R I C E 2 1 / 0 7 / 1 9 7 9
Hospital Record No Age

Gender Male Female

3 3

NHIS no. 6 0 2 8 9 2 3 0

M H B 8 / 0 1 9 4 3 4

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2
/ / / / / /

Absconded/Discharged against medical advice

Duration(days)

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Specialty Description: A N T E - N A T A L

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /

G-DRG

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10

G-DRG
O P D C 0 2 A

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O P D C 0 2 A

Tariff Amount
. 1 3 . 2 7 . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 3 . 2 7

Date Date

Signed Signed

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 2 9 9 3 9 5 5 M H B 5 / 0 0 7 2 7 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 2 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K O T E I C O M F O R T 2 1 / 1 2 / 1 9 7 9 Hospital Record No Age Gender Male Female 3 3 NHIS no.

Qty Total Cost . 2 7 Date Date Signed Signed . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 4 5 2 5 2 1 8 M H C 1 / 0 3 7 2 3 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: S U R G I C A L O U T P A T I E N T D E P A R Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 2 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A M O A H V I C T O R I A 2 7 / 0 8 / 1 9 3 7 Hospital Record No Age Gender Male Female 7 5 NHIS no.

. . . 9 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 6 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 6 6 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 9 . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 6 A Tariff Amount . . 6 6 Date Date Signed Signed . Qty Total Cost .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 3 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A T T A A H A K O S U A M A R Y Age Gender Male Female 0 1 / 0 4 / 1 9 7 9 Hospital Record No 3 3 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Caesarian Section (DIST Date 1 4 / 0 2 / 2 0 1 2 / / / / G-DRG O B G Y 3 2 A . 7 8 4 4 9 8 7 6 M H C 2 / 0 0 3 4 5 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y Specialty Description: A N T E .

1 8 5 . . 7 7 . . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 8 5 . . 7 7 Date Date Signed Signed . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O B G Y 3 2 A Tariff Amount . 0 G-DRG Intrauterine hypoxia first noted Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 P 2 0 . . . Qty Total Cost . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 3 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O B E N U C E P H A S T E Y E Age Gender Male Female 2 2 / 0 2 / 1 9 7 6 Hospital Record No 3 6 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 5 8 9 2 8 9 7 9 M H Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: Specialty Description: U N B U N D L E D S E R V I C E S Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

2 0 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 4 . . . . 0 0 1 4 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code Tariff Amount . 0 . . . 2 0 Date Date Signed Signed .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG Date 1 4 / 0 2 / 1 2 1 4 / 0 2 / 1 2 / / / / / / G-DRG I N V E S 7 5 I N V E S 2 4 Lipid Profile Bue & Creatinine Medicines (to be filled by all health care providers dispensing medicines) Price . Qty Total Cost . .

M E T R O 3 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth T A G O E A M A ( M A T I L D A ) 0 4 / 0 2 / 2 0 1 2 Hospital Record No Age < 1 Gender Male Female NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 4 8 1 8 5 1 0 8 M H C 2 / 0 0 5 0 0 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 2 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: P A E D Specialty Description: P A E D I A T R I C S Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code P A E D 1 4 C Tariff Amount 1 1 7 . 2 6 Date Date Signed Signed . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 A 4 1 . . . . . Qty Total Cost . 4 G-DRG P A E D 1 4 C Septicemia due to anaerobes Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 6 . . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 1 7 .

M E T R O 3 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A D J E I M A B E L 1 4 / 0 5 / 1 9 8 4 Hospital Record No Age Gender Male Female 2 8 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 5 6 5 1 3 8 6 1 M H C 2 / 0 0 1 4 4 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 2 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y Specialty Description: O B S T E T R I C S .G Y N E C O L O G Y Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Spontaneous Vaginal Del Date 1 4 / 0 2 / 2 0 1 2 / / / / G-DRG O B G Y 3 4 A .

6 G-DRG Delayed delivery after spontaneou Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . 1 6 Date Date Signed Signed . 1 6 . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 5 6 . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 7 5 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O B G Y 3 4 A Tariff Amount 5 6 . . . . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 3 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth T A M A N J A F E L I C I A 2 5 / 0 9 / 1 9 8 7 Hospital Record No Age Gender Male Female 2 5 NHIS no. 7 3 6 0 1 7 5 1 M H C 1 / 0 3 6 1 6 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: P O S T N A T A L C L I N I C Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

Qty Total Cost . . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 2 7 Date Date Signed Signed . . . 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 3 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth T A G O E M A T I L D A 2 6 / 0 6 / 1 9 7 2 Hospital Record No Age Gender Male Female 4 0 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 4 8 1 8 5 1 0 8 M H C 2 / 0 0 2 5 9 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 Date Date Signed Signed . . . 1 3 . . 2 7 . Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . Y Age Gender Male Female 2 9 NHIS no. 4 3 0 0 6 9 3 0 M H B 5 / 0 2 0 9 5 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 3 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Z I L E V U P H I L I P I N E 2 0 / 1 1 / 1 9 8 3 Hospital Record No E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 Date Date Signed Signed . Qty Total Cost . . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 3 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K U M A E S T H E R 1 8 / 0 3 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Spontaneous Vaginal Del Date 1 4 / 0 2 / 2 0 1 2 / / / / G-DRG O B G Y 3 3 A . 7 6 6 1 0 1 8 5 M H C 1 / 0 3 5 4 0 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y Specialty Description: A N T E .

3 2 Date Date Signed Signed . Qty Total Cost . . . . 4 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 4 7 . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . 3 2 . . 9 G-DRG Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O B G Y 3 3 A Tariff Amount .

M E T R O 3 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K U M A E S T H E R 1 8 / 0 3 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no. 7 6 6 1 0 1 8 5 M H C 1 / 0 3 5 4 0 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

Qty Total Cost . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 Date Date Signed Signed . . . 2 7 . 1 3 . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 4 1 7 6 8 9 5 M H B 4 / 0 1 8 8 6 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 3 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth T E T T E H G A H R E B E C C A 2 3 / 0 7 / 1 9 8 0 Hospital Record No Age Gender Male Female 3 2 NHIS no.

.Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . 2 7 Date Date Signed Signed . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 . . Qty Total Cost . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .

M E T R O 4 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth H A Y F O R D A L I C E 2 3 / 0 4 / 1 9 8 9 Hospital Record No Age Gender Male Female 2 3 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 6 7 0 4 8 6 7 M H C 1 / 0 3 4 9 4 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . 1 3 . . . 2 7 Date Date Signed Signed . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .

G Y N E C O L O G Y Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Caesarian Section (DIST Date 1 4 / 0 2 / 2 0 1 2 / / / / G-DRG O B G Y 3 2 A . 7 7 4 7 8 3 0 1 M H A 9 / 0 1 0 0 9 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 2 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y Specialty Description: O B S T E T R I C S . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 4 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth L E G I B O D I A N A 1 5 / 0 1 / 1 9 7 2 Hospital Record No Age Gender Male Female 4 0 NHIS no.

. . . . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O B G Y 3 2 A Tariff Amount 1 8 5 . 7 7 . 0 G-DRG Intrauterine hypoxia first noted Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 P 2 0 . 7 7 Date Date Signed Signed . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 8 5 . . . Qty Total Cost . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 4 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A W U D U Z A L I Y A 0 6 / 0 2 / 1 9 7 3 Hospital Record No Age Gender Male Female 3 9 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 1 5 2 5 9 8 1 6 M H C 1 / 0 3 7 4 2 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . 2 7 Date Date Signed Signed . . . 1 3 . Qty Total Cost . . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 4 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A M P A W G L O R I A 2 5 / 0 6 / 1 9 7 4 Hospital Record No Age Gender Male Female 3 8 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 6 9 1 9 9 4 9 M H A 9 / 0 0 5 9 1 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

2 7 Date Date Signed Signed . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 4 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D A G B A N A R E B E C C A 1 2 / 1 2 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 1 0 0 6 6 9 1 6 7 M H B 1 / 0 0 9 8 2 1 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . 1 3 . . 2 7 . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Qty Total Cost . 2 7 Date Date Signed Signed .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 5 9 0 3 7 1 7 1 M H B 9 / 0 2 4 2 8 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 4 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K O F F I E D E L A L I C E L E S T I N E Age Gender Male Female 0 3 / 0 6 / 1 9 8 2 Hospital Record No 3 0 NHIS no.

. 2 7 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 Date Date Signed Signed . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 1 3 . . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 4 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth I S A T S U P R I N C I L L A 3 0 / 1 1 / 1 9 9 0 Hospital Record No Age Gender Male Female 2 2 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 8 6 7 4 7 0 2 M H C 2 / 0 0 4 0 5 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 . . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 1 3 . Qty Total Cost . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 Date Date Signed Signed . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 4 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Q U A R S H I E L Y D I A M I L L S Age Gender Male Female 1 2 / 1 1 / 1 9 8 0 Hospital Record No 3 2 NHIS no. 7 7 7 3 7 2 4 7 M H B 7 / 0 2 3 5 9 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

2 7 . . . Qty Total Cost . 1 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 Date Date Signed Signed . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 4 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A G Y E I G R A C E 0 4 / 0 6 / 1 9 7 4 Hospital Record No Age Gender Male Female 3 8 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 8 8 1 5 2 8 3 M H A 9 / 0 1 7 2 4 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 4 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . . . Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . 2 7 Date Date Signed Signed . 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 2 7 .

1 2 6 3 M H B 5 / 0 2 7 3 8 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 4 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth N K R U M A H H O L I E V E 1 6 / 0 8 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 . . . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . Qty Total Cost . . 1 3 . . 2 7 Date Date Signed Signed .

3 0 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y Specialty Description: O B S T E T R I C S . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 1 9 5 9 5 7 6 3 M H B 6 / 0 0 7 4 5 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 6 / 0 1 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) .M E T R O 5 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Q U I S T C A T H E R I N E 0 4 / 0 7 / 1 9 8 4 Hospital Record No Age Gender Male Female 2 8 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.G Y N E C O L O G Y Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Spontaneous Vaginal Del Date 1 5 / 0 2 / 2 0 1 2 / / / / G-DRG O B G Y 3 3 A .

9 G-DRG Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 4 7 . 3 2 Date Date Signed Signed . . . . . . . 3 2 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O B G Y 3 3 A Tariff Amount 4 7 . Qty Total Cost . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 5 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A B B E Y A G N E S 1 9 / 0 8 / 1 9 7 9 Hospital Record No Age Gender Male Female 3 3 NHIS no. 4 2 9 2 8 4 6 4 M H B 7 / 0 1 7 2 3 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . Qty Total Cost . 2 7 . 1 3 . . . 2 7 Date Date Signed Signed . .

1 5 3 3 2 3 6 1 M H B 9 / 0 1 0 3 9 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: P O S T N A T A L C L I N I C Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 5 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A N A B I L A E M E L I A 2 4 / 0 6 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.

. . . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . 2 7 . . 2 7 Date Date Signed Signed . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 1 3 . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 5 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K P O D O I V Y 2 5 / 0 4 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no. 7 1 7 9 5 6 4 9 M H B 9 / 0 1 2 7 2 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 Date Date Signed Signed . . . 2 7 . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . 1 3 . . Qty Total Cost .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 5 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A R H I N S A H A G N E S 1 5 / 0 6 / 1 9 7 9 Hospital Record No Age Gender Male Female 3 3 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 3 1 9 1 M H B 6 / 0 1 2 9 0 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. 2 7 Date Date Signed Signed . . . 1 3 . . . . 2 7 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .

M E T R O 5 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth W I R E D U V E R O N I C A 0 3 / 1 0 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . A M C 0 0 6 1 M H B 6 / 0 2 1 4 8 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: P O S T N A T A L C L I N I C Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 . Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 2 7 . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . 2 7 Date Date Signed Signed . .

4 2 3 9 7 6 2 1 M H B 5 / 0 1 7 4 7 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 1 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: A S U R Specialty Description: S U R G I C A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Operations on the Ureth Date 1 5 / 0 2 / 2 0 1 2 / / / / G-DRG A S U R 2 1 A . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 5 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A H E D O R H O P E A N T H O N Y Age Gender Male Female 2 9 / 0 3 / 1 9 8 3 Hospital Record No 2 9 NHIS no.

. Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 5 4 1 . Qty Total Cost . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code A S U R 2 1 A Tariff Amount 5 4 1 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 N 3 4 . . . . . 3 2 . . - G-DRG Urethritis and urethral syndrome Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . 3 2 Date Date Signed Signed .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 5 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K O O M S O N T H E R E S A 2 2 / 0 2 / 1 9 8 5 Hospital Record No Age Gender Male Female 2 7 NHIS no. 3 8 5 7 M H B 7 / 0 0 0 6 4 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. 2 7 . . . . Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 Date Date Signed Signed . . 1 3 . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 4 2 5 1 3 1 9 2 M H B 6 / 0 2 4 7 5 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 2 2 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 7 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: M E D I Specialty Description: M E D I C A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 5 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O C L O O G L O R I A 3 0 / 0 6 / 1 9 4 1 Hospital Record No Age Gender Male Female 7 1 NHIS no.

. 3 7 . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 E 1 4 . . . . . . . Qty Total Cost . 3 7 Date Date Signed Signed . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 6 2 . 1 G-DRG M E D I 0 3 A With ketoacidosis Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code M E D I 0 3 A Tariff Amount 1 6 2 . . .

M E T R O 5 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O C L O O G L O R I A 3 0 / 0 6 / 1 9 4 1 Hospital Record No Age Gender Male Female 7 1 NHIS no. 4 2 5 1 3 1 9 2 M H B 6 / 0 2 4 7 5 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 5 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 0 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: M E D I Specialty Description: M E D I C A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

. . . 8 8 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code M E D I 0 3 A Tariff Amount 2 4 3 . 8 8 Date Date Signed Signed . Qty Total Cost . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 E 1 4 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 2 4 3 . . . 1 G-DRG M E D I 0 3 A With ketoacidosis Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 4 1 3 0 M H C 0 / 0 2 5 9 2 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 6 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A C H E A M P O N G E R N E S T I N A 0 3 / 0 7 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

2 7 Date Date Signed Signed . . . 2 7 . . . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 1 6 8 3 3 7 9 1 M H C 1 / 0 1 0 5 5 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: P O L Y C L I N I C Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 6 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A L I Y A H A Y A 2 2 / 1 0 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no.

. . 6 6 Date Date Signed Signed . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 E 2 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 9 . 2 G-DRG O P D C 0 6 A Diabetes insipidus Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 6 6 . . Qty Total Cost . 9 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 6 A Tariff Amount . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 6 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A B U B A K A R I F A T I 0 3 / 0 5 / 1 9 8 5 Hospital Record No Age Gender Male Female 2 7 NHIS no. 3 4 2 9 0 8 9 3 M H C 1 / 0 1 4 9 2 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. Qty Total Cost . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed . 2 7 . . . . . 1 3 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

6 6 6 5 7 5 3 7 M H A 9 / 0 2 9 7 1 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 2 7 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 1 2 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: A S U R Specialty Description: S U R G I C A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 External Hernia Repair Date 1 5 / 0 2 / 2 0 1 2 / / / / G-DRG A S U R 2 0 A .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 6 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O D I A M P O M A H V I D A Age Gender Male Female 0 1 / 0 1 / 1 9 3 5 Hospital Record No 7 7 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 6 8 . . 8 7 . . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 K 4 0 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code A S U R 2 0 A Tariff Amount 1 6 8 . . with o Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . 0 G-DRG Bilateral inguinal hernia. . 8 7 Date Date Signed Signed . . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 1 5 3 2 9 4 6 8 M H Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: M A L E O U T P A T I E N T D E P A R T M E N Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 6 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth N O R T E Y E E D M U N D 2 1 / 0 3 / 1 9 3 2 Hospital Record No Age Gender Male Female 8 0 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

. . 6 6 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 M 2 5 . . . 5 G-DRG O P D C 0 6 A Pain in joint Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 9 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 6 A Tariff Amount . . 6 6 Date Date Signed Signed . . 9 . Qty Total Cost . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 6 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A S A N T E S H E R R Y 0 1 / 1 0 / 1 9 8 4 Hospital Record No Age Gender Male Female 2 8 NHIS no. 6 0 9 1 6 2 9 5 M H B 0 / 0 1 9 9 1 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

. 1 3 . . 2 7 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 Date Date Signed Signed . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . Qty Total Cost . . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 6 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A S A R E G I F T Y 1 4 / 0 9 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . A Y A 0 0 4 2 9 5 M H C 1 / 0 1 8 4 9 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . 1 3 . . 2 7 Date Date Signed Signed . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . . 2 7 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

6 8 3 0 1 4 1 6 M H C 1 / 0 0 5 6 7 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 6 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Q U A Y E L Y D I A 2 7 / 0 9 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no.

Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . 2 7 . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Qty Total Cost . . 1 3 . 2 7 Date Date Signed Signed . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 1 1 7 3 9 0 2 M H B 8 / 0 3 1 3 2 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 1 6 / 0 2 / 2 0 1 2 / / / / Absconded/Discharged against medical advice Duration(days) 1 Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O B G Y Specialty Description: O B S T E T R I C S .G Y N E C O L O G Y Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Spontaneous Vaginal Del Date 1 5 / 0 2 / 2 0 1 2 / / / / G-DRG O B G Y 3 4 A .M E T R O 6 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O W U S U M A R Y S E K Y E R E Gender Male Female 0 2 / 0 6 / 1 9 8 5 Hospital Record No Age 2 7 NHIS no.

. . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 5 6 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 7 5 . . Qty Total Cost . . . 1 6 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O B G Y 3 4 A Tariff Amount 5 6 . . 6 G-DRG Delayed delivery after spontaneou Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 1 6 Date Date Signed Signed .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 5 8 9 2 5 7 2 1 M H C 1 / 0 2 5 3 6 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: S U R G I C A L O U T P A T I E N T D E P A R Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 6 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth T U R K S O N S A M U E L 2 5 / 1 0 / 1 9 6 5 Hospital Record No Age Gender Male Female 4 7 NHIS no.

. 6 6 Date Date Signed Signed . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 9 . 9 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 6 A Tariff Amount . . . . . 6 6 . . . Qty Total Cost . . 9 G-DRG O P D C 0 6 A Crush Injury Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 T 1 4 .

2 3 6 9 M H B 7 / 0 1 0 0 3 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 7 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M U D O R V I C T O R I A 1 3 / 0 2 / 1 9 8 1 Hospital Record No Age Gender Male Female 3 1 NHIS no.

1 3 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 . Qty Total Cost . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 Date Date Signed Signed .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 7 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth H A M M O N D V I D A 2 5 / 0 7 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 3 0 9 4 M H B 9 / 0 1 8 9 9 1 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 . 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . 2 7 Date Date Signed Signed . Qty Total Cost . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 5 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A R H I N S A H A G N E S 1 5 / 0 6 / 1 9 7 9 Hospital Record No Age Gender Male Female 3 3 NHIS no. 3 1 9 1 M H B 6 / 0 1 2 9 0 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Qty Total Cost . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 Date Date Signed Signed . 1 3 . . 2 7 . . . . .

3 8 5 7 M H B 7 / 0 0 0 6 4 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 5 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K O O M S O N T H E R E S A 2 2 / 0 2 / 1 9 8 5 Hospital Record No Age Gender Male Female 2 7 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

1 3 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . . . 2 7 Date Date Signed Signed . . 2 7 . Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 6 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A C H E A M P O N G E R N E S T I N A 0 3 / 0 7 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no. 4 1 3 0 M H C 0 / 0 2 5 9 2 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

2 7 . . . . . . . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 Date Date Signed Signed . 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 3 4 2 9 0 8 9 3 M H C 1 / 0 1 4 9 2 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 6 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A B U B A K A R I F A T I 0 3 / 0 5 / 1 9 8 5 Hospital Record No Age Gender Male Female 2 7 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . 1 3 . . . 2 7 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Qty Total Cost . 2 7 Date Date Signed Signed . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . .

M E T R O 6 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A S A N T E S H E R R Y 0 1 / 1 0 / 1 9 8 4 Hospital Record No Age Gender Male Female 2 8 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 6 0 9 1 6 2 9 5 M H B 0 / 0 1 9 9 1 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Qty Total Cost . . . . . 2 7 Date Date Signed Signed . . . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 6 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A S A R E G I F T Y 1 4 / 0 9 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no. A Y A 0 0 4 2 9 5 M H C 1 / 0 1 8 4 9 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed . . . . . 1 3 . . Qty Total Cost . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 6 8 3 0 1 4 1 6 M H C 1 / 0 0 5 6 7 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 6 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Q U A Y E L Y D I A 2 7 / 0 9 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no.

. .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Qty Total Cost . . . 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 . . . 2 7 Date Date Signed Signed .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 7 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O T O O E L I Z A B E T H 1 9 / 0 2 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 2 9 5 2 2 1 9 M H C 1 / 0 2 1 8 8 9 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . 2 7 . . 2 7 Date Date Signed Signed . . . 1 3 .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 8 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O B U O B I T H E R E S A 0 4 / 0 6 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. A Y A 0 0 4 4 8 5 M H B 7 / 0 3 4 2 8 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . . 2 7 Date Date Signed Signed . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 1 3 . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Qty Total Cost .

M E T R O 8 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A R T H U R R E G I N A 1 0 / 0 1 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no. 5 6 4 9 0 1 8 2 M H C 1 / 0 0 0 6 8 1 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. 2 7 . . . . . . 2 7 Date Date Signed Signed . Qty Total Cost . . . 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .

6 2 4 3 9 0 5 5 M H C 1 / 0 1 4 6 3 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 8 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M I N N E A U X M A T I L D A 0 5 / 1 2 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Qty Total Cost . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 1 3 . 2 7 Date Date Signed Signed . . . . . 2 7 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 2 5 1 2 5 7 5 M H A 9 / 0 1 5 1 4 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 8 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A W U K U A F I A 0 5 / 0 4 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

Qty Total Cost . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . 2 7 Date Date Signed Signed . 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 . .

M E T R O 8 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A D A D E V O H A G N E S 0 2 / 0 7 / 1 9 8 5 Hospital Record No Age Gender Male Female 2 7 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 3 3 7 8 8 8 2 M H C 1 / 0 1 3 4 7 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . 1 3 . . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 Date Date Signed Signed . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 3 4 0 7 3 9 1 M H C 1 / 0 2 1 3 4 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 8 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O B E N G J O Y C E 2 7 / 0 9 / 1 9 8 1 Hospital Record No Age Gender Male Female 3 1 NHIS no.

. . . . . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 2 7 Date Date Signed Signed . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 8 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D O R V I C O M F O R T 0 5 / 0 9 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 5 7 3 2 5 2 5 5 M H B 7 / 0 1 7 9 4 1 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

2 7 Date Date Signed Signed . 1 3 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 . . . Qty Total Cost . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . .

M E T R O 8 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth I C I B U D E B O R A 2 5 / 0 3 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no. 7 3 4 8 3 1 0 4 M H C 1 / 0 2 0 6 7 0 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . . 1 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . 2 7 . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 2 7 Date Date Signed Signed . Qty Total Cost .

M E T R O 8 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Y A W S O N R E B E C C A 2 8 / 0 8 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 3 2 3 8 4 0 8 M H B 8 / 0 2 5 1 0 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

2 7 Date Date Signed Signed . 1 3 . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . . . 2 7 . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 8 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth B O T C H W A Y F L O R E N C E 2 3 / 1 1 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no. 7 4 1 8 3 1 7 4 M H C 1 / 0 2 6 9 4 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

Qty Total Cost . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 . 2 7 Date Date Signed Signed . . . 2 7 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 3 9 2 1 9 8 8 M H C 1 / 0 1 4 1 7 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 9 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O T E N G G E R T R U D E 2 5 / 0 9 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no.

Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 . Qty Total Cost . 2 7 Date Date Signed Signed . . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 1 3 . . . .

M E T R O 9 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A M E D E K A R E G I N A 0 1 / 0 8 / 1 9 8 1 Hospital Record No Age Gender Male Female 3 1 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 3 1 0 4 4 7 2 M H C 1 / 0 2 1 8 7 8 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. 1 3 . . Qty Total Cost . . . . 2 7 Date Date Signed Signed .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 5 7 8 3 0 4 8 3 M H C 1 / 0 1 8 9 6 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 9 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth E S S I N E R O S E M O N D 2 9 / 1 1 / 1 9 8 0 Hospital Record No Age Gender Male Female 3 2 NHIS no.

9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 Date Date Signed Signed . 1 3 . . . 2 7 . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Qty Total Cost . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 4 3 6 8 2 1 5 M H B 7 / 0 1 8 1 5 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 9 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A S A N T E T A N I A 0 7 / 0 5 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

.Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . 2 7 Date Date Signed Signed . 2 7 . . . . . Qty Total Cost . . 1 3 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .

M E T R O 9 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth B A K A I P R I S C I L L A 1 2 / 1 0 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 4 0 7 2 1 8 1 M H C 1 / 0 2 5 0 2 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

. . . Qty Total Cost . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . 2 7 Date Date Signed Signed . 2 7 . 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 9 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Y E B O A H J U L I E T 1 6 / 0 3 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no. 7 5 2 1 8 5 0 2 M H C 1 / 0 2 9 1 5 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

1 3 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . Qty Total Cost . 2 7 . . 2 7 Date Date Signed Signed . . . . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . .

M E T R O 9 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O D A M T E Y A B I G A I L 2 5 / 1 2 / 1 9 8 7 Hospital Record No Age Gender Male Female 2 5 NHIS no. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 5 4 5 7 3 8 8 M H C 1 / 0 2 9 4 1 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

Qty Total Cost . . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 2 7 Date Date Signed Signed . 2 7 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 4 2 3 7 1 3 0 5 M H A 9 / 0 4 0 3 8 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 9 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A M A R T E Y B E R N I C E 1 4 / 0 5 / 1 9 7 8 Hospital Record No Age Gender Male Female 3 4 NHIS no.

1 3 . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . . Qty Total Cost . 2 7 . . . 2 7 Date Date Signed Signed . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . 7 5 4 6 7 4 1 0 M H C 1 / 0 3 1 4 8 6 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 9 8 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A L H A S S A N A Y I S H A 2 5 / 0 9 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no.

. . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . Qty Total Cost . . 2 7 Date Date Signed Signed . 1 3 . . 2 7 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 .

7 4 7 2 2 7 5 3 M H C 1 / 0 2 7 3 8 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 9 9 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth O B E N G F E L I C I A 1 1 / 0 5 / 1 9 8 6 Hospital Record No Age Gender Male Female 2 6 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.

Qty Total Cost .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . 2 7 . . . . . 2 7 Date Date Signed Signed . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . .

M E T R O 1 0 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D O T S E Y M A R Y 2 3 / 0 6 / 1 9 8 2 Hospital Record No Age Gender Male Female 3 0 NHIS no. 7 4 7 0 0 9 3 2 M H B 4 / 0 0 1 1 8 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

. .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 2 7 Date Date Signed Signed . . 1 3 . Qty Total Cost . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 5 2 8 0 3 6 8 M H B 5 / 0 2 8 0 3 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 1 0 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth L A V O E E L I Z A B E T H 2 8 / 0 6 / 1 9 8 3 Hospital Record No Age Gender Male Female 2 9 NHIS no.

. 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 2 7 . 2 7 Date Date Signed Signed . . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 4 9 3 9 2 0 4 M H B 0 / 0 0 8 3 3 1 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 0 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M A R T E Y V I D A 1 9 / 0 9 / 1 9 7 5 Hospital Record No Age Gender Male Female 3 7 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

. . . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 2 7 Date Date Signed Signed . . . . 1 3 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 1 0 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth S O S I R E G I N A 1 5 / 0 4 / 1 9 7 9 Hospital Record No Age Gender Male Female 3 3 NHIS no. 6 4 7 0 1 7 7 7 3 M H C 1 / 0 3 2 7 0 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. 2 7 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Qty Total Cost . . 2 7 Date Date Signed Signed . 1 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 0 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth K O M E S U O M A R Y 1 2 / 1 1 / 1 9 7 4 Hospital Record No Age Gender Male Female 3 8 NHIS no. 7 4 0 1 2 5 9 0 M H B 0 / 0 3 6 0 4 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed . . . 2 7 . . 1 3 . Qty Total Cost . . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 6 6 4 0 5 5 4 8 M H C 1 / 0 3 4 6 0 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 0 5 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M O H A M M E D H A S S A N A S A L I F U Age Gender Male Female 0 5 / 0 5 / 1 9 8 8 Hospital Record No 2 4 NHIS no.

. . 1 3 . Qty Total Cost . . . . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . 2 7 . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 2 7 Date Date Signed Signed . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . C H R I S T I A N A 1 6 / 0 6 / 1 9 7 5 Hospital Record No Age Gender Male Female 3 7 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 7 2 6 9 9 5 3 M H C 2 / 0 0 0 4 1 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .M E T R O 1 0 6 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth D E B R A H A .

2 7 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Qty Total Cost . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . 2 7 Date Date Signed Signed . 1 3 . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . .

NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 0 7 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth A M P O M E V I D A 1 1 / 0 8 / 1 9 8 0 Hospital Record No Age Gender Male Female 3 2 NHIS no. 7 7 6 5 4 8 8 3 M H C 2 / 0 0 1 1 9 2 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10
O 8 0 . 9

G-DRG
O P D C 0 2 A

Normal Pregnancy

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O P D C 0 2 A

Tariff Amount
. 1 3 . 2 7 . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 3 . 2 7

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

1 0 8 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

T W U M R I T A 0 5 / 0 8 / 1 9 8 4
Hospital Record No Age

Gender Male Female

2 8

NHIS no. 7 6 7 2 2 4 3 6

M H C 1 / 0 3 5 2 7 6

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /

Absconded/Discharged against medical advice

Duration(days)

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Specialty Description: A N T E - N A T A L

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /

G-DRG

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description
1 2 3 4 5

ICD-10
O 8 0 . 9

G-DRG
O P D C 0 2 A

Normal Pregnancy

Date
/ / / / / / / / / /

G-DRG

Medicines (to be filled by all health care providers dispensing medicines) Price
. . . . .

Qty

Total Cost
. . . . .

Code

Client Claim Summary Type of Service
A B C D In-Patient Out-Patient Investigations Pharmacy

G-DRG/Code
O P D C 0 2 A

Tariff Amount
. 1 3 . 2 7 . .

Signature

Name

(Health Facility Insurance Officer)

TOTAL Scheme Use Only
Date Received Signed Action 1 Action 2

1 3 . 2 7

Date Date

Signed Signed

NATIONAL HEALTH INSURANCE SCHEME
Claim Form
(Regulation 62) Name of Scheme Claim Number Form No. HI Code:

M H D I S T R I C T M U T

A Y A W A S O

S U B - M E T R O

1 0 9 Date of Claim 0 4 / 0 4 / 2 0 1 2

Client Information
Surname Other Names Date of Birth

A G B E T S I A F A D E L A L I 2 9 / 0 9 / 1 9 7 4
Hospital Record No Age

Gender Male Female

3 8

NHIS no. 7 7 2 0 6 3 1 1

M H B 6 / 0 1 5 5 1 5

Services Provided (to be filled by all health care providers)
Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision

DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2
/ / / / / /

Absconded/Discharged against medical advice

Duration(days)

Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C

Specialty Description: A N T E - N A T A L

Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date
/ / / / / /

G-DRG

. . 2 7 Date Date Signed Signed . . Qty Total Cost . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 . 2 7 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 1 0 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth N A R T E Y M E R C Y 2 3 / 0 7 / 1 9 8 7 Hospital Record No Age Gender Male Female 2 5 NHIS no. 7 4 8 9 6 1 3 6 M H B 4 / 0 1 3 7 6 3 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

. 2 7 Date Date Signed Signed . Qty Total Cost . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 . . . 1 3 . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B . 7 4 2 8 8 1 3 7 M H C 2 / 0 0 2 4 3 7 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .M E T R O 1 1 1 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth Y U S S I F H A B I B A 1 5 / 0 5 / 1 9 7 7 Hospital Record No Age Gender Male Female 3 5 NHIS no.NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .

. Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . . Qty Total Cost . 2 7 Date Date Signed Signed . . .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 . . 1 3 . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price .

7 8 4 7 8 0 7 1 M H C 1 / 0 3 4 1 4 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.M E T R O 1 1 2 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M U M U N I M O N I C A 0 7 / 1 2 / 1 9 7 3 Hospital Record No Age Gender Male Female 3 9 NHIS no.

2 7 . . . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . 1 3 . . . Qty Total Cost . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . 2 7 Date Date Signed Signed . . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . .

HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .M E T R O 1 1 3 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M U M U N A F A R I D A 2 9 / 0 9 / 1 9 8 0 Hospital Record No Age Gender Male Female 3 2 NHIS no. 7 8 0 1 7 8 0 4 M H C 1 / 0 3 4 9 9 4 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E .

. . Qty Total Cost . . . . 2 7 . 2 7 Date Date Signed Signed .Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 G-DRG O P D C 0 2 A Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . 1 3 . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount .

M E T R O 1 1 4 Date of Claim 0 4 / 0 4 / 2 0 1 2 Client Information Surname Other Names Date of Birth M U D O R V I C T O R I A 1 3 / 0 4 / 1 9 8 1 Hospital Record No Age Gender Male Female 3 1 NHIS no.N A T A L Procedures(s) (to be filled by all health care providers who have provided out or in-patient services) Description Procedure 1 Procedure 2 Procedure 3 Date / / / / / / G-DRG .NATIONAL HEALTH INSURANCE SCHEME Claim Form (Regulation 62) Name of Scheme Claim Number Form No. 7 7 6 3 1 2 6 7 M H B 7 / 0 1 0 0 3 5 Services Provided (to be filled by all health care providers) Type of Service Outpatient Diagnostic All Inclusive Outcome Discharged In-patient Unbundled Pharmacy 1st Visit/Admission 2nd Visit/Discharge 3rd Visit Died Transferred Out 4th Visit Date(s) of Service Provision DD/MM/YYYY 1 5 / 0 2 / 2 0 1 2 / / / / / / Absconded/Discharged against medical advice Duration(days) Type of Attendance Chronic Follow-Up Emergency/Acute Episode Specialty Code: O P D C Specialty Description: A N T E . HI Code: M H D I S T R I C T M U T A Y A W A S O S U B .

Diagnosis(es) (to be filled by all health care providers who have provided out or in-patient services) Description Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Investigations (to be filled by all health care providers providing diagnostic services) Description Investigation 1 Investigation 2 Investigation 3 Investigation 4 Investigation 5 Description 1 2 3 4 5 ICD-10 O 8 0 . . 1 3 . . Signature Name (Health Facility Insurance Officer) TOTAL Scheme Use Only Date Received Signed Action 1 Action 2 1 3 . . . . . . 2 7 Date Date Signed Signed . . . Code Client Claim Summary Type of Service A B C D In-Patient Out-Patient Investigations Pharmacy G-DRG/Code O P D C 0 2 A Tariff Amount . 9 G-DRG O P D C 0 2 A Normal Pregnancy Date / / / / / / / / / / G-DRG Medicines (to be filled by all health care providers dispensing medicines) Price . Qty Total Cost . 2 7 .