Get This Form Is Designed To Be Completed In Sections

Completing the This Form Is Designed To Be Completed In Sections is essential for efficiently processing out-patient claims. This guide will walk you through each section and provide clear instructions to help you fill out the form correctly.

Follow the steps to successfully complete your form.

1. Click the ‘Get Form’ button to access the form and open it in the editor for online completion.
2. Begin with Part 1: Patient Information. Enter the patient's surname and other names accurately. Provide the membership ID number and NHIF number. Indicate the relationship of the patient to the principal member, and fill in the date of birth, gender, and contact number. Certify the correctness of the information by signing and dating the form.
3. Proceed to Part 2: Hospital Particulars. The hospital representative must fill out details such as the facility name, facility code, outpatient number, and scheme type, ensuring all fields are completed accurately.
4. Move to Part 3: Nature of Treatment. This section requires input from the clinician or specialist. Document the reason for the patient's visit, the treatment condition, and outcomes by selecting the appropriate options. Ensure to include the clinician's or specialist's names and any referral information if applicable.
5. In Part 4: Treatment Authentication, the hospital representative must fill in the date of attendance, check-in and check-out times, primary diagnosis, and the necessary diagnosis and procedure codes. Provide a detailed description of the services rendered along with their costs.
6. Complete Part 5: Patient's Authentication. The patient acknowledges the receipt of treatment by certifying the accuracy of the costs and information provided. The patient must sign and date the form.
7. Review the completed form for accuracy. Ensure all sections are filled out and required attachments, such as invoices and referral letters, are included. Once satisfied, you can save changes, download, print, or share the form as needed.

Start completing your form online to ensure timely processing of your claims.