NHIF 8d/6-7-15

Revised 2020

SURGICAL SERVICES PRE-AUTHORIZATION FORM

PLEASE BE AS COMPREHENSIVE AND ACCURATE AS POSSIBLE WHEN COMPLETING THIS FORM. ERRORS OR OMMISSIONS MAY DELAY APPROVAL.

SECTION 1: PATIENT INFORMATION (To be filled by the Patient/Guardian)

Surname: Other Names: County:

Patient’s ID No/Birth Cert./ Patient’s
NHIF Member No:
Notification No: Phone No:
Relationship to Principal Member: Self: ☐ Spouse:☐ Child: ☐ Principal Member Phone No:

If patient is below 18 years, Name of Guardian: Relationship to patient:

Do you have any other MEDICAL insurance cover? Yes ☐ No ☐ If YES, give details:

PATIENT OR AUTHORISED PERSON’S DECLARATION: I certify that the above information is correct and give specific consent for
surgery to be done. I understand that it is an offence to knowingly make any false statement for purposes of obtaining any benefit
under NHIF Act.
Signature: _______________________________ Date: __________________________________
SECTION 2: HOSPITAL INFORMATION

Hospital Name: Hospital Representative Information

Hospital Code: Facility Level: Name:

Phone No: Id No: Designation:

Provisional Diagnosis: ICD 10 Code:

Is the member Co-insured (check): Yes ☐ No ☐ If YES, give detalis:

The Beneficiary is eligible for this benefit: Cost of procedure: (Attach pro-forma invoice)

Comprehensively ☐ Non – comprehensively ☐

HOSPITAL DECLARATION: This is to certify that to the best of my knowledge, the information contained in this form, and any
attachments provided is true, accurate, and complete and the requested service(s) is necessary to the health of the patient. I
understand that it is an offence to knowingly make any false statement for purposes of obtaining any benefit under NHIF Act.
Facility stamp
Signature: ________________________________ Date: ______________________________

SECTION 3: PRACTITIONER’S DECLARATION-SURGEON

Surgical Procedure requested for: Procedure Code Request date: DD/MM/YYYY

Scheduled Date: DD/MM/YYYY

Clinical Indication for the procedure: Is the patient’s condition related to:

a. Employment: Yes ☐ No ☐

b. Auto or other Accident: Yes ☐ No ☐

Name: Surgical speciality:

KMPDC Reg. No: ID No: Phone No:

Effective 1st May 2020 Page 1 of 2

 NHIF 8d/6-7-15

Revised 2020

PRACTITIONER DECLARATION: This is to certify that the intended surgical procedure is rightly indicated for the presenting condition
of the beneficiary and the desired outcome shall be of value in managing the condition. Attached is evidence supporting the decision
to perform the operation following review by myself.

(tick as appropriate) Radiological exam: Laboratory tests: Case Summary:

Facility stamp
Signature: ………………………………………………… Date: ……………………………………………………….

SECTION 4: PRACTITIONERS DECLARATION-ANAESTHESIST

Surgical Procedure requested for: Procedure Code Request date: DD/MM/YYYY

Scheduled Date: DD/MM/YYYY

Type of anaesthesia Is the patient’s condition related to:

General anaesthesia ☐ Spinal Block ☐ a. Employment: Yes ☐ No ☐

Local Anaesthesia ☐ Sedation ☐ b. Auto or other Accident: Yes ☐ No ☐

Name: Speciality:

KMPDC Reg. No: ID No: Phone No:

PRACTITIONER DECLARATION: This is to certify that the anaesthesia method selected is appropriate for the presenting condition
of the beneficiary contingent to review by myself: Signature: …………………………………… Date: ……………………………………

Notice: Any person/institution who/which knowingly files a statement of request or claim containing any misrepresentation or false,
incomplete, or misleading information may be guilty of medical fraud punishable under law or as per the statutes of NHIF operation.

❖ All fields in this form are mandatory and MUST be completed to inform pre-authorization decision.
❖ Clinical justification and results of preliminary diagnostic examinations, where necessary, shall accompany the request.
❖ Payment for services rendered is subject to verification of outcomes of care and beneficiary eligibility as at the date of
service provision. Contractual obligations with the provider take precedence.
❖ Medical co-insurance declaration is Mandatory, failure to which approval will be withheld or monies recovered in case of
falsification to obtain benefits.
❖ PATIENT OR AUTHORISED PERSON’S DECLARATION: This declaration provides that the Principal member and beneficiary
details are accurate and complete as per the form, that the medical information and treatment plan herein is accurate and can
be utilized for medical insurance purposes.
❖ HOSPITAL DECLARATION: This declaration provides that the hospital is declared and contracted, and is operational under the
provisions on location, hospital code and contracted services. It also provides that the member/beneficiary is eligible for access
to the contracted benefits as per the clauses on “OBLIGATIONS OF THE HEALTH FACILITY”, and the terms of engagement. It
also provides that the hospital has taken due diligence to identify the beneficiary and provided necessary details on the eligible
benefits and financial liability.
❖ PRACTITIONER DECLARATION: The listed beneficiary has presented to the practitioner for clinical management and that the
practitioner is duly qualified and registered by the relevant authority in Kenya.
❖ THEATRE LIST: All surgical requests must have an attached theatre List

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