PATIENT DETAILS

THIS FORM MUST BE COMPLETED FOR EVERY PATIENT RECEIVING TREATMENT. PLEASE COMPLETE A SEPERATE CLAIM FORM FOR EACH VISIT AND ATTACH YOUR INVOICE FOR PROCESSING. THE

PATIENT SHOULD BE GIVEN A DUPLICATE COPY FOR THEIR RECORDS. PLEASE ATTACH DETAILED INVOICE WHERE POSSIBLE TO EXPEDITE PAYMENT. PLEASE COMPLETE FORM IN BLOCK LETTERS.

IMPORTANT: THE HERITAGE INSURANCE COMPANY KENYA WILL REJECT ILLEGIBLE OR INCOMPLETE CLAIMS

MAIN MEMBER DETAILS

MEDICAL CLAIM FORM BLUE

INVOICE NUMBER :

SERVICE PROVIDER DETAILS

NAME OF CLINIC CONSULTING PHYSICIAN

ANOTHER SOURCE, AND THAT THE PATIENT IS A MEMBER OR DEPENDANT ON BLUE HEALTH INSURANCE. I AUTHORISE THE

PROVIDER OF SERVICES TO DISCLOSE THE NATURE OF ILLNESS TO BLUE FOR ITS CONFIDENTIAL USE AND I AGREE THAT

NO AWARDS WILL BE MADE FOR THIS TREATMENT UNLESS CONTRIBUTIONS ARE RECEIVED IN RESPECT OF THE PERIOD

OF TREATMENT. LIBERTY HEALTH RESERVES THE RIGHT TO RECOVER ANY AMOUNTS PAID TO PROVIDERS IN EXCESS OF

BENEFITS DIRECTLY

SIGNED __________________________________________________ DATE ____________________________

PROVIDER’S DECLARATION

I CERTIFY THAT THE ABOVE PATIENT HAS RECEIVED THE SERVICES & TREATMENT NOTED ON THIS FORM, DIAGNOSED AND ADMINISTERED BY MYSELF AND THAT THIS

CLAIM IS IN ACCORDANCE WITH MY SPECIFIED TREATMENT

SIGNED ______________________________________________ DATE

CfC House, Mamlaka Road P.O BOX 30390 - 00100, Nairobi, Kenya

FIRST NAME SURNAME

MEMBER NO DEP. CODE GENDER DOB.

FIRST NAME SURNAME

EMPLOYER

DIAGNOSISCODE (TICK)DIAGNOSISCODE (TICK)DIAGNOSISCODE (TICK)DIAGNOSISCODE (TICK)

ALLERGIC RHINITISJ30C-SECTIONO82MALARIAB54PHARYNGITISJ02

ANAEMIAD64DENTAL CARIESK02MYOPIAH52PNEUMONIAJ18

ANTENATAL SCREENINGZ36DERMATITISL30

SPONTANEOUS BIRTHO80

0190 - GP0191 - SPECIALIST11001 - OPTICAL8101 - DENTALOTHERCOST

IS THIS A MATERNITY RELATED CLAIM?

No