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Insurance card and application-related forms
Benefit and claims-related forms
Insurance card and application-related forms
form
example
reference
“Notification of Health Insurance Dependent (Change)(Increase)”
“Notification of Health Insurance Dependent (Change)(Reduction)”
Example(Increase)
Example(Reduction)
Reference
“Application Form for Reissue of Health insurance card / Elderly benefits card (Loss/Damage)”
Example (Card loss)
Example (Card damage)
Example (Unnecessary for re-issue)
Reference
“Application Form for Certification as Voluntarily and Continuously Insured Person”
Example
Reference
“Application Form for Loss as Voluntarily and Continuously Insured Person”
Example
Reference
“Application Form for Adding a Dependent”
Reference
Benefit and claims-related forms
form
example
reference
"Application Form for Medecal Care Expenses (Temporary Payment)"
"Receipts (A Detail) written opinion of medical doctor Statements (Doctors Proof)"
Example (Insured Person)
Example (Dependents)
Reference
"Application Form for Medical Care Expenses (Orthosis・Therapeutic use Glasses)"
Example
Reference
"A Picture of Orthosis"
Reference
"Appication Form for Medical Care Expenses (Treatments for Acupuncture・Moxa cautery)"
Example
Reference
"Application Form for Medical Care Expenses (Japanese Traditional Massage or the other Massage)"
Example
Reference
“Claim for Injury and Sickness Allowance/ Additional Sum”
Example
Reference
“Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum”
Example
Reference
“Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf)”
Example
Reference
“Claim for Maternity Allowance”
Example
Reference
“Claim for Funeral Expenses/Funeral Costs”
Example of completed form (Insured Person)
Example of completed form (Dependents )
Reference
“Request for issuance of Maximum Co-payment Certificate for Health Insurance”
Example
Reference
“Application Form for Issuance of Certificate of Receipt of Medical Expenses to Treat a Specified Disease”
Example
Reference
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Procedures
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If you lose your health insurance card
Moving and job transfer
Marriage
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After you leave your employer
When you are exempt from the long-term care insurance program
Childbirth
If you take time off from work for childbirth
Death
If you paid the entire medical care cost up front
If you take time off from work due to sickness
If you become sick or are injured due to the actions of another party
When you incur high medical care costs
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