Outpatient/inpatient claim intake with itemized costs, an automatically totaled claim amount, and receipt attachments.
What's included
This template asks for diagnosis and treatment details, for the member or a dependant who may be a child.
Unda Forms is hosted in Nairobi, Kenya, but parts of the service run outside Kenya — email, for example. See the list of providers. Health data carries extra obligations under Kenya's Data Protection Act; check them with your adviser before collecting real responses.
Recommended for
Your policy details, the treatment received and the amounts claimed. Have your receipts and any medical reports to hand.
Preview mode — this is the real form renderer, but responses are not submitted.
