NHIS - Referal-Form

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NHIS - Referal-Form

Uploaded by

Adewale Alaba

We take content rights seriously. If you suspect this is your content, claim it here.

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Download as PDF, TXT or read online on Scribd

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DEFENCE HEALTH MAINTENANCE LTD

THE NATIONAL HEALTH INSURANCE SCHEME

THE MILITARY HMO

REFERRAL FORM NHIS ID No. ……………….

DATE______________________ HMO CODE…………………

FROM (HEALTH FACILITY) _____________________________________________________

REFERRED TO _______________________________________________________________
SERVICE No. ________________________________________________________________
PATIENT’S NAME____________________________________________________________
PATIENT’S RESIDENTIAL ADDRESS_______________________________________________
PATIENT’S PHONE NUMBER(S) _________________________________________________
CLINICAL FINDINGS _______________________________________________________
______________________________________________________________________
______________________________________________________________________
INVESTIGATION__________________________________________________________
______________________________________________________________________
______________________________________________________________________
PROVISIONAL DIAGNOSIS __________________________________________________
REASON FOR REFERRAL ____________________________________________________
NAME OF REFERRING PERSONNEL____________________________________________

SIGNATURE & STAMP _____________________________________________________

DATE______________________________

……………………………………………………………………………………………………………………………………………

ACKNOWLEGEMENT SLIP
RECIEPIENT’S FACILITY _____________________________________________________
PATIENT’S NAME__________________________________________________________
NHIS ID No.______________________________________________________________
ACTION TAKEN___________________________________________________________
___________________________________________________________________________

DOCTOR’S NAME & SIGNATURE_________________________________________________

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NHIS - Referal-Form

Uploaded by

NHIS - Referal-Form

Uploaded by

DEFENCE HEALTH MAINTENANCE LTD

THE NATIONAL HEALTH INSURANCE SCHEME

THE MILITARY HMO

DATE______________________ HMO CODE…………………

FROM (HEALTH FACILITY) _____________________________________________________

SIGNATURE & STAMP _____________________________________________________

DOCTOR’S NAME & SIGNATURE_________________________________________________

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