Refund Claim Form – Maisha Health Fund

Fill In The Refund Claim Form

Service Provider Details

Service Provider

Employer/Account Holder

Date

Patient's Details

Surname

First Names

Gender
Male Female

Date Of Birth

Relationship to Member

Member Number

Patient Prefix

Medical Claim Details

Expense Type e.g Prescription Drugs, X-ray Service

Date of Expense

Quantity

Total

Bank Details

Name Of Member

Membership Number

Bank

Branch

Branch Code

Account Name

Account Number

Physical Address

Contact Person

Contact Number

Upload/Attach following documents

Attach receipt of the cash payment made Choose a file

Max. size: 64.0 MB

Attach prescription where applicable Choose a file

Max. size: 64.0 MB

Attach Service Provider Claim form, signed and stamped by service provider Choose a file

Max. size: 64.0 MB