SHA Claims Form
The SHA Claims Form is the official form used to submit a claim under the Social Health Authority (SHA) in Kenya. It is issued under the Social Health Insurance Act, 2023 and the Social Health Insurance (General) Regulations, 2024 and is titled “Claims.”
The form is identified as Form 3 (r. 58(4)) and is designed to capture information about the health care provider, patient, visit, diagnosis, treatment and SHA health benefits being claimed.
If you are looking for the SHA Claims Form PDF, you can download the form using the link below and use this guide to understand the information required in each section before completing or submitting it.
Download SHA Claims Form PDF
You can download the SHA Claims Form PDF here:
Official SHA Claims Form: Download the SHA Claims Form PDF
The form is three pages long and contains sections for health care provider details, patient details, patient visit details, SHA health benefits, declarations and official use.
What is SHA Claims Form?
The SHA Claims Form is a claim document used to record and submit details relating to health services provided to a patient.
Unlike the SHA registration form, which is primarily concerned with registering a member and recording their personal details, the SHA Claims Form focuses on a health care service or patient visit and the information needed to support a claim.
The form collects information from the health care provider and patient and includes details such as the patient’s SHA number, visit or admission dates, diagnosis, procedures, claim amounts and declarations.
The form also contains important instructions for claim filing. It states that the form should be completed using capital letters, the appropriate boxes should be ticked and supporting documents should be submitted within seven (7) days from the discharge date.
Important SHA Claims Form Instructions
Before filling out the form, pay attention to the claim-filing reminders at the top.
The form instructs applicants to:
- Use capital letters and tick the appropriate boxes.
- Submit the form together with supporting documents within seven (7) days from the discharge date.
- Complete all fields because they are marked as mandatory.
- Provide accurate information because false or incorrect information may result in criminal or administrative liabilities.
The form also warns that errors or omissions may delay claim payments.
This makes accuracy particularly important when completing the SHA Claims Form.
Sections of SHA Claims Form
The form is divided into several sections, each dealing with a different part of the claim.
Part I – Health Care Providers Details
The first section is Part I – Health Care Providers Details.
It requires:
- Health Provider Identification Number
- Name of Health Care Provider/Facility
The health care provider or facility should ensure that these details are entered correctly.
There is also a space at the top of the form for the Claim No.
Part II – Patient Details
The second section captures information about the patient.
a. Patient’s Full Name
The form provides separate fields for:
- Last Name
- First Name
- Middle Name
The patient’s name should be entered accurately.
b. Social Health Authority Number
The form asks for the patient’s Social Health Authority Number.
This is an important identification field in the claim form and should be entered correctly.
c. Residence
The patient’s residence is also required.
d. Other Health Insurance
The form asks: “Do you have another Health Insurance: (If Yes, State which one)”
If the patient has another health insurance arrangement, the relevant information should be provided as requested.
e. Relationship to the Principal
The form also asks for the patient’s relationship to the principal.
This section is therefore useful for identifying whether the patient is the principal member or is connected to the principal in another capacity.
Part III – Patient Visit Details
The third section deals with the patient’s visit and treatment.
a. Referral Information
The form asks whether the patient was referred by another health care provider.
The options include:
- No
- If Yes
Where the patient was referred, the form asks for the Name of Referring Health Care Provider/Facility.
b. Visit Type
The form provides options for the type of visit:
- Inpatient
- Outpatient
- Day-care
The appropriate option should be selected.
c. Visit or Admission Date
The form includes a field for the Visit/Admission Date.
For an inpatient case, this relates to the admission. For an outpatient service, the form notes that the date of service is the date of admission.
d. OP/IP Number
The form also includes an OP/IP No. field.
This should be completed as applicable to the patient’s visit.
e. New or Return Visit
The form provides a field to indicate whether the visit is a New/Return Visit.
f. Discharge Date
For applicable cases, the discharge date should be entered.
This is particularly important because the form’s claim-filing reminder refers to submitting supporting documents within seven days from the discharge date.
g. Rendering Physician
The form asks for the Rendering Physician Name and Registration No.
The appropriate physician information should be entered in this section.
Type of Accommodation
The SHA Claims Form includes a field for the Type of Accommodation.
The form lists the following options:
- Female Medical
- Male Medical
- Female Surgical
- Male Surgical
- Gynaecology
- Maternity
- NBU
- Psychiatric Unit
- Burns
- ICU
- HDU
- NICU
- Isolation
The appropriate type of accommodation should be indicated based on the patient’s stay.
Patient Disposition Upon Discharge
The form includes Patient Disposition upon discharge (select only 1).
The available options are:
- Improved
- Recovered
- Leave Against/Discharged Against Medical Advice
- Absconded
- Died
Only one option should be selected, as instructed on the form.
Referral Details
The form includes a section for patients who were referred.
If the patient was not referred, the form instructs the person completing the section to enter N/A.
Where applicable, the form requests:
- Name of Referral Institution
- Reason/s for referral
This information helps document the patient’s referral history.
Admission Diagnosis
The SHA Claims Form provides a section for Admission Diagnosis/es.
The diagnosis or diagnoses associated with the patient’s admission should be entered in the appropriate space.
Discharge Diagnosis
The form also has a section for Discharge Diagnosis/es.
It provides fields for:
- Diagnosis
- ICD-11 Code/s
- Related Procedure/s, if any
- Date of Procedure
These details should correspond with the patient’s treatment and discharge information.
SHA Health Benefits
One of the major sections of the form is SHA Health Benefits. The form provides a table for recording information relating to the services and amounts included in the claim. The table contains the following columns:
| Field | Information |
|---|---|
| Date of Admission | Date the patient was admitted |
| Date of Discharge | Date the patient was discharged |
| Case Code | Applicable case code |
| ICD 11 / Procedure Code | Applicable diagnosis or procedure code |
| Description | Description of the service or item |
| Preauth No. | Pre-authorisation number |
| Bill Amount | Amount billed |
| Claim Amount | Amount being claimed |
The form provides multiple rows for entering the relevant services. It also includes a Total section at the bottom of the table.
Important note for outpatient services
The form specifically states: “For outpatient services, Date of service is the Date of admission.”
This is an important instruction to consider when completing the relevant dates.
Additional Information About Length of Stay
The form provides a space for explaining: “Any unforeseen circumstances or additional information that led to an increased length of stay for this admission?”
Where applicable, the relevant circumstances or additional information should be provided.
This section gives the health care provider an opportunity to explain circumstances that resulted in a longer admission.
Patient’s or Authorised Person’s Declaration
The SHA Claims Form contains a Patient’s/Authorised Person’s Declaration.
The declaration confirms that the patient or authorised person has received the stated treatment and that the information provided is correct.
It also states that falsifying information to obtain a benefit under the SHI Act 2023 is an offence.
The declaration provides fields for:
- Names (Majina)
- Signature (Sahihi)
- Date (Tarehe)
The person completing the declaration should provide the requested information and sign where indicated.
Hospital Declaration
The form also contains an E. Hospital Declaration section.
The hospital certifies that, to the best of its knowledge, the information contained in the claim and any attachments provided is true, accurate and complete and that the services rendered are necessary to the patient’s health.
The declaration also addresses the amount payable to the hospital for the services rendered.
The section provides space for:
- Hospital signature
- Date
- Facility stamp
The hospital should therefore ensure that this section is completed appropriately before the claim is submitted.
For Official Use Only
The final section is marked “F. FOR OFFICIAL USE ONLY.” This section is not intended for the patient or general applicant to complete.
It includes:
- Receiving Officer Name
- Date
- SHA Receiving
- Stamp
Leave this section for the relevant officials.
SHA Claims Form Requirements
The most important requirements stated directly on the form are:
1. Use capital letters
The claim-filing instructions state that the form should be completed using capital letters.
2. Tick the appropriate boxes
Where the form provides options, select the appropriate box. This applies to areas such as visit type and patient disposition.
3. Complete all fields
The form states that all fields are mandatory and that incomplete forms will not be processed.
This means the person completing the claim should carefully review the entire form before submission.
4. Submit supporting documents
The form instructs claimants to submit the form together with supporting documents within seven days from the discharge date.
5. Provide accurate information
The form warns that false or incorrect information may result in criminal or administrative liabilities.
It also states that errors or omissions may delay claim payments.
How To Fill SHA Claims Form
Step 1: Download the SHA Claims Form PDF
Download the current SHA Claims Form PDF and print it if you are completing the form manually.
Step 2: Complete the health care provider details
Enter the Health Provider Identification Number and the name of the health care provider or facility.
Step 3: Enter the patient’s details
Provide the patient’s full name, SHA number, residence, information about other health insurance where applicable and relationship to the principal.
Step 4: Complete the patient visit details
Indicate whether the visit was inpatient, outpatient or day-care. Enter the admission or visit date, OP/IP number, whether it was a new or return visit, discharge date and the rendering physician’s details.
Step 5: Complete the diagnosis and referral information
Provide referral details where applicable and enter the admission and discharge diagnoses. Where required, provide ICD-11 codes, related procedures and procedure dates.
Step 6: Enter SHA health benefits information
Complete the SHA Health Benefits table. Enter the relevant dates, case code, ICD-11 or procedure code, description, pre-authorisation number, bill amount and claim amount.
Calculate and enter the total where applicable.
Step 7: Add information about an increased length of stay
If unforeseen circumstances or additional information resulted in an increased length of stay, provide the relevant explanation in the designated section.
Step 8: Complete the patient or authorised person’s declaration
The patient or authorised person should complete the declaration section, including their name, signature and date.
Step 9: Complete the hospital declaration
The hospital should complete its declaration, including the required signature, date and facility stamp.
Step 10: Leave the official-use section blank
The For Official Use Only section should be completed by the relevant SHA receiving officials.
Step 11: Attach supporting documents
Attach the required supporting documents and submit the claim within the timeframe stated on the form.
SHA Claims Form PDF Download
If you searched for SHA Claims Form PDF, the document is the three-page claims form issued under the Social Health Insurance Act, 2023 and the Social Health Insurance (General) Regulations, 2024.
Download the official SHA Claims Form PDF: SHA Claims Form PDF
The form is marked Form 3 (r. 58(4)) and is titled Claims.
Common Mistakes to Avoid When Filling SHA Claims Form
Because the form states that errors and omissions may delay claim payments, it is important to review the information before submission.
Avoid:
- Leaving mandatory fields blank.
- Failing to tick the appropriate boxes.
- Entering information in lowercase when the form instructs you to use capital letters.
- Providing incorrect patient identification details.
- Omitting referral information where applicable.
- Leaving diagnosis or procedure information incomplete.
- Entering incorrect admission or discharge dates.
- Failing to complete the SHA Health Benefits table.
- Forgetting the required declarations, signatures or facility stamp.
- Submitting the claim without the required supporting documents.
- Providing false, incomplete or misleading information.
SHA Claims Form Frequently Asked Questions
1. What is the SHA Claims Form?
The SHA Claims Form is the official claims form used to document and submit information relating to health care services provided to a patient under the Social Health Authority.
2. Where can I download the SHA Claims Form PDF?
You can download the SHA Claims Form PDF from the official SHA website using the download link provided in this guide.
3. How many pages is the SHA Claims Form?
The SHA Claims Form provided here consists of three pages.
4. Who fills the SHA Claims Form?
The form contains information relating to the health care provider, patient and treatment. It also contains declarations for the patient or authorised person and the hospital, while the final section is reserved for official use.
5. What information is required on the SHA Claims Form?
The form requests health care provider details, patient details, referral information, visit and admission details, diagnosis information, procedure information, SHA health benefits and claim amounts.
6. What are the claim-filing instructions on the SHA Claims Form?
The form instructs users to complete it in capital letters, tick the appropriate boxes, submit supporting documents within seven days from the discharge date and complete all fields.
7. What happens if information is missing from the claim form?
The form states that incomplete forms will not be processed and warns that errors or omissions may delay claim payments.
8. Does the SHA Claims Form require supporting documents?
Yes. The claim-filing reminders instruct the claimant to submit the form with supporting documents within seven days from the discharge date.
9. What is the SHA Health Benefits section?
The SHA Health Benefits section contains a table for recording admission and discharge dates, case codes, ICD-11/procedure codes, descriptions, pre-authorisation numbers, bill amounts and claim amounts.
10. What is the patient disposition section?
The patient disposition section records the patient’s status upon discharge. The form provides options including improved, recovered, discharged against medical advice, absconded and died, with an instruction to select only one.
SHA Claims Form Checklist
Before submitting the claim, review the following:
- Use capital letters throughout the form.
- Tick the appropriate boxes.
- Complete all mandatory fields.
- Enter the correct health provider identification number.
- Enter the patient’s full name and SHA number.
- Complete the patient’s visit or admission details.
- Provide referral information where applicable.
- Enter admission and discharge diagnoses.
- Provide ICD-11 and procedure information where applicable.
- Complete the SHA Health Benefits table.
- Enter the relevant bill and claim amounts.
- Provide an explanation if an unforeseen circumstance increased the length of stay.
- Complete the patient or authorised person’s declaration.
- Complete the hospital declaration.
- Add the required signatures, dates and facility stamp.
- Attach supporting documents.
- Submit the claim within seven days from the discharge date.
- Leave the “For Official Use Only” section for the relevant officials.
The SHA Claims Form is an important document for recording and submitting health care claims under the SHA framework. Because the form states that all fields are mandatory and that errors or omissions may delay claim payments, it is important to complete every applicable section carefully.
If you need the form, use the official SHA Claims Form PDF link above, check the claim-filing reminders before filling it out, provide the required supporting documents and ensure that the relevant declarations and signatures have been completed before submission.