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Search for:
Business Banking
Corporate and Trade Finance
Sidian Credible
Business Account
Trade Finance
Treasury Services
Microbanking
Nawiri Account
Ungana Group Account
Microfinance Individual Loan
Chama Biashara Loan
SME Banking
Business Account
Tabibu Solution
SME Offering
Loans
Personal Bank Loans
Our SME Loans
Microbanking Loans
Personal Banking
Current Account
Savings Account
Personal Bank Loans
Sidian Insurance
General Insurance
Motor Insurance
Life Insurance
Digital Banking
Debit/ Credit Cards
Online Banking
Personal Online Banking
Corporate Online Banking
SidianVIBE
About Sidian Bank
About Sidian Bank
Our Core Values
Our History
Our People
Shareholder Information
Financial Statements
Careers
Branches & ATMs
Contact-us
News
Font Size
Normal
Large
Extra Large
Search for:
Online Banking
Personal Online Banking
Corporate Online banking
Sidian Credible
About Sidian Bank
Branches & ATMs
Careers
Business Banking
Business Account
Microbanking
SME Banking
Trade Finance
Treasury Services
Personal Banking
Current Account
Savings Account
Loans
Sidian News
Sidian Insurance Agency
General Insurance
Life Insurance
Motor Insurance
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Contact-us
Health/ Medical Claim Form
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Health/ Medical Claim Form
Health/ Medical Claim Form
fkm-sidian
2019-12-09T22:26:15+03:00
Health/ Medical Claim Form
Health/ Medical Claim Form
Patients Details
Name
*
First
Middle
Last
Email
*
Patient’s Member Number
*
Date of Birth
*
MM slash DD slash YYYY
Patient/Guardian Telephone No.
*
Name of Principal Member
First
Middle
Last
Relationship to Principal Member
Principal Member’s Employer
Details of Illness
Nature of claim:
Outpatient
Inpatient
Date of first onset of symptoms/illness
MM slash DD slash YYYY
Date of first consultation with doctor
MM slash DD slash YYYY
Diagnosis
In your opinion, what is the cause of this illness
In your opinion, is this illness chronic or recurring
Consultant referred to
Attending Doctor
Details of Expenses
Consultation Fees
Drugs or Expenses
Lab/X-RAY/ Other Diagnostic Services
AUXILIARY SERVICES: DENTAL/OPTICAL ETC
HOSPITALIZATION (NET NHIF)
Phone
This field is for validation purposes and should be left unchanged.
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