Tumaini Haven Patient Assistance/Support Program

Financial
assistance

Counseling &
adherence

Insurance
support

Drug delivery
to doorstep

Nurse homecare/
administration

Patient information

Patient full name (as on ID)

Date of birth

National ID / Passport

Patient phone

+254

Alternative phone

+254

Email address

County

Location/Town/Area

Consented contact / caregiver

If the patient is a minor or requires a caregiver, please fill in the details below.

Contact full name

Contact phone

+254

Email address

Treating physician information

Physician full name

Contact phone

+254

Facility location (city/town)

Name of treatment facility (hospital/clinic)

Authorization & certification

Who is completing this form?

Patient

I am applying for myself

Caregiver

Legal representative / guardian

Doctor / clinician

Authorized representative

PSP nurse

Authorized representative

InsightsIQ

https://theinsightsiq.com/

Support & Inquiries support.tumaini@insightsiq.co

Contact Hotlines +254 740 554 372 +254 114 666 164 +254 715 853 512

Tumaini HavenPatient Support Program

Patient information

Consented contact / caregiver

Treating physician information

Authorization & certification

Privacy & program consent declaration

Enrollment successful!

Tumaini Haven
Patient Support Program