Get Nhif Diagnostic Imaging Pre Authorization Form

Completing the Nhif Diagnostic Imaging Pre Authorization Form is essential for obtaining prior authorization for necessary imaging services such as MRI and CT scans. This guide provides clear instructions to ensure that all required sections of the form are filled out correctly and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. In Section 1, provide patient information including the surname, other names, relationship to the principal member, patient ID number, member ID number, NHIF member number, and phone number. Be sure to certify the information is correct and provide your signature along with the date.
3. In Section 2, the requesting doctor needs to specify the type of imaging service being requested (CT Scan or MRI) and provide details like the primary diagnosis, ICD 10 code, servicing location (inpatient or outpatient), and date of service.
4. In Section 3, the requesting specialist/consultant must fill in their information including facility name, facility code, contact person, patient OPC/IPC number, email, phone number, their names, KMPDB registration number, practice specialty, and justification for the radiology procedure.
5. In Section 4, complete the details of the service rendering practitioner or facility including the facility name, hospital code, radiologist’s names, registration number, and a brief outcome of the procedure. The radiologist must also sign and date this section.
6. Lastly, ensure that all sections are completed and any necessary attachments are included, then save your changes, download, print, or securely share the completed form as required.

Complete the Nhif Diagnostic Imaging Pre Authorization Form online to ensure you receive timely approval for your imaging services.