N.H.I.

F 38
Issue No: 01
NATIONAL HOSPITAL INSURANCE FUND
P. O. Box 30443 - 00100, NAIROBI, KENYA
Website: www.nhif.or.ke, E-Mail: info@nhif.or.ke

CHOICE OF OUTPATIENT MEDICAL FACILITY FORM

Guidelines:
1. Principal Members are required to forward a duly completed form to be submitted to the nearest N.H.I.F
Office.
2. To select a medical facility, please refer to the list of N.H.I.F accredited health facilities available in the
N.H.I.F Website and N.H.I.F offices Countrywide.
3. To access benefits one MUST be duly registered by filling N.H.I.F Registration Form (N.H.I.F 2), and
declare their dependants.
A. PRINCIPAL MEMBER'S DETAILS
SURNAME: OTHER NAMES: ....
N.H.I.F No.(Mandatory): .................. I.D. No.(Mandatory): .................................
PERSONAL No.: ..................... JOB GROUP: ....
DATE OF BIRTH(DD/MM/YY): ............................GENDER (Male/Female): ........................
MOBILE PHONE No.: .... EMAIL ADDRESS: .....................
EMPLOYER STATION.....
B. MEMBER, DEPENDANTS AND PREFERRED MEDICAL FACILITY DETAILS

Date of Birth
Name
DD
Principal
Member
Spouse
Child 1
Child 2
Child 3

MM

YY

Gender
M/F

I.D./Birth
Certificate No.

Preferred Medical Facility

Code

Name

C. CERTIFICATION
I certify that the information provided is correct to the best of my knowledge.
Name of Employee: ................................ Signature: ... Date: ...
D. FOR OFFICIAL USE
Approved By: ............................ Signature: ....... Date: ......