Adamawa State
Contributory Health
management Agency
ASCHMA

© 2024 Adamawa State Contributory Health Management Agency.

Beneficiary Enrollment

*Upload Picture

*Plan Type

Title

*First Name

Other Name

*Last Name

Email Address

*Mobile Number

*Date of Birth

Age

*Gender

Male

Female

*Marital Status

*Residential Address

*State of Residence

*LGA of Residence

*Ward

*Provider

*State of Origin

*LGA of Origin

Nationality

Religion

Tribe

*Occupation

NIN

Height (m)

Weight (kg)

Blood Pressure (mmHg/mmHg)

BMI

Are you on any Health Insurance Plan?

Yes

Disabilities

Visual impairment

Hearing impairment

Physical impairment

Intellectual impairment

Speech impairment

Albino

Lepromatous (Leprosy)

Others (Specify)

None

Next of Kin Information

*Last Name

*First Name

Other Name

*Relationship

*Mobile Number

*Contact Address

*State

*LGA

Spouse Information

Upload Picture

Last Name

First Name

Date of Birth

No of Children

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