NHIA Claim Form | DripDental

NHIA Claim Form

Patient Information

Surname

Other Name

Patient No.

NHIA No.

Date of Birth

Age

Gender

Month of Claim (Batch)

Claim Check Code

Service Provided

Type of Service (a)

Type of Service (b)

Outcome

Duration of Spell (days)

Type of Attendance

Speciality Code

Procedures

Description	Code	Unit Price	Qty	Total	Date	Action

Investigations

Description	Code	Unit Price	Qty	Total	Date	Action

Diagnosis

Description	ICD-10 Code	Type	Date Recorded	Action

Medicines

Description	Dosage	Frequency	Price	Qty	Total	Date	Code	Action

Client Claim Summary

Type of Service	G-DRG/Code	Tariff Amount
A - In-Patient
B - Out-Patient
D - Pharmacy
C - Investigations
Total

For Scheme Use Only

Date Received:

Action 1:

Date:

Date Current:

Action 2:

Date: