Fillable NHI Bahamas Enrolment Form 2020

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NHI Bahamas Enrolment Form 2020

On average this form takes 15 minutes to complete

The NHI Bahamas Enrolment Form 2020 form is 4 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 49 other fields

Country of origin: OTHERS
File type: PDF

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www.nhibahamas.gov.bs
info@nhibahamas.gov.bs | (242) 396-8500
Beneficiary Enrolment Form
KEEPINGYOURINFORMATIONCONFIDENTIAL
The information that you will provide is for the purposes of determining your eligibility for the National Health Insurance
(NHI) Programme facilitating enrolment and for purposes connected with the NHI Programme. Enrolment will require
the National Health Insurance Authority (NHIA) to request data and/or information from the National Insurance Board
(NIB) using the National Insurance Number provided in your application. By checking “Accept” you agree to the NHIA
requesting data and/or information from NIB for the purposes of determining your eligibility for the National Health
Insurance (NHI) Programme, facilitating enrolment and for purposes connected with the NHI Programme and further
you are providing your consent to NIB for NIB to release the information unto NHIA. The information received will be
treated as strictly confidential and the NHIA will fully comply with the respective data privacy laws and policies.
The information you provide during enrolment is needed to document your enrolment in the National Health
Insurance Programme. The principal use of this information will be to:
• Identify your enrolment in the Programme;
• Verify your eligibility for health benefits services, and
• Coordinate payment of claims for benefits rendered under the Programme.
Please review the disclaimer above. You must check “Accept” before you can proceed. If you have any questions or
disagree with the above, contact NHI Bahamas at info@nhibahamas.gov.bs.
I accept the conditions as laid out in the Enrolment Disclaimer above.
INSTRUCTIONS
1. What you need to submit the form:
a An NIB Smart Card.
b Proof of Bahamian citizenship or legal residency.*
c Proof of residency in The Bahamas for the last 6 months.*
d Private insurance policy group ID number and Member ID number (if you have one).
e Your top 3 Primary Care Provider choices.
*Details available on www.nhibahamas.gov.bs
2. Complete the form, sign and date, and return to your local enrolment office, together with your supporting
documents. You will have to submit a separate application form for each child and any other legal dependents.
Please print clearly.
Male
Female
Date of Birth (DD/MM/YYYY) REQUIRED
DEPENDENTDECLARATION
This section is for you to declare yourself as a dependent (as defined by the NIB) or as a parent/guardian
filling out this form on behalf of your dependent
If you are either a dependent or a parent/guardian filling out this application on behalf of your dependent,
please check “Yes” below. If not, please select “No”.
REQUIRED
Yes No
If you selected “Yes” above, please list the parent/guardian’s National Insurance Number(s) below:
National Insurance Number #1 REQUIRED National Insurance Number #2
Name must be entered exactly as it appears on your NIB Smart Card.
First Name REQUIRED Middle Name Last Name REQUIRED
Island of Residence REQUIRED
CONTACTINFORMATION
Please indicate your preferred contact method.
Please select one option.
REQUIRED
Please indicate if you consent to receive SMS messages to your mobile phone.
Messages may include information about NHI Bahamas. If you do not consent, you will receive the information through other
means. Note that standard text message rates will apply if you select “Yes”.
Please select one option.
REQUIRED
Yes No
Email addresses will be used to send you a confirmation receipt with a Submission ID and to allow access to an online portal.
When available, you will receive an email to activate your account to access this portal.
Email Address
Morning
(9am—12pm)
Aernoon
(12pm—5pm)
Evening
(5pm—8pm)
Primary Phone Number
REQUIRED
Secondary Phone Number
Choose one
REQUIRED
Mobile Home Work
Choose one
Mobile Home Work
Morning
(9am—12pm)
Aernoon
(12pm—5pm)
Evening
(5pm—8pm)
Please provide at least one phone number and specify
whether it is a mobile, home or work number.
What is your preferred time to be contacted for each number?
You may select multiple options.
Phone Email
APPLICANT’SPERSONALINFORMATION
National Insurance Number REQUIRED
Residential Address
House or Apartment # Street Name
City/ Town/ Village
Island Country
PRIVATEHEALTHCOVERAGE
Do you currently have private health insurance?
Please select one option.
REQUIRED
Yes No
If you selected “Yes” to the question above, please complete the remaining fields on this page.
Please note this section is for the purpose of coordination of benefits. NHI Bahamas may liaise with your insurance carrier
to verify this information.
Name of Insurance Carrier/Company
REQUIRED
Type of Insurance
Please select one option.
REQUIRED
Group Individual
Group ID Number REQUIRED Member ID Number REQUIRED
PROVIDERSELECTIONANDRANKING
Please provide your ranking for 3 Providers in order of preference.
For more information on the Providers eligible to provide NHI Bahamas services, refer to the list located at
www.nhibahama s.gov.bs/enrol and available in person at the enrolment locations.
Preference #1: Island
REQUIRED
Provider Facility Physician Selection
Preference #2: Island REQUIRED
Provider Facility Physician Selection
Preference #3: Island REQUIRED
Provider Facility Physician Selection
Name must be entered exactly as it appears on your NIB Smart Card.
First Name REQUIRED Middle Name Last Name REQUIRED
Consent Statements
I am authorized to provide consent on behalf of the person I am filling out this application for
(only for Parent/Guardian or Caretaker)
I verify that the information provided is up-to-date, true and accurate.
I acknowledge that I have read and understand the NHI Bahamas Data Privacy Policy or I confirm that the contents above were
read to me by an authorized person, if necessary. (You can find a copy of the NHI Bahamas Data Privacy Policy on our website. )
I consent to my personal and health information being collected, used, and disclosed for NHI Bahamas
programme purposes, in accordance with NHI Bahamas Data Privacy Policy.
I consent to NHI Bahamas accessing my NIB account for purposes of verifying my identity and determining eligibility.
NHI Bahamas will only have access to view my NIB account and will not make any changes to my account information.
Signature Date
CONSENTANDSUBMISSION
Are you filling out this form for yourself or on behalf of another applicant?
Please select one option.
REQUIRED
Myself On behalf of another
If you are applying on behalf of another person, please provide your information below.
Relationship Type to Applicant (if filling out on behalf of another)
Please define (i.e Parent, Guardian, Caretaker, Other)
National Insurance Number
Date of Birth MM/DD/ YY
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NHI Bahamas Enrolment Form 2020

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Completed 16 July 2020

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