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Application forms

Health insurance card/dependents

Purpose Title Application form Excel
Word
Example
Increase in number of dependents (required for all) Notification of Dependent(S) <Transfer>
・Spouse Survey Form (Form 1)
・Child (other than newborn) Survey Form (Form 2)
・Other than spouse and child Survey Form (Form 3)
・Living apart Allowance Report
・Also see “Documents to Attach for Dependent Certification” and attach all required documents.

Decrease in number of dependents Notification of Dependent(S) <Transfer>
Change/correction of dependent’s name/date of birth Notification of Change in Dependent Name/Date of Birth
Reissuing a lost health insurance card Request for Reissue of Health Insurance Card
Unable to return health insurance card, etc. Notification of Loss of Health Insurance Card
Remaining a member of the Health Insurance Association after you leave your employer Notifications regarding Voluntarily and Continuously Insured Person
Name change while Voluntarily and Continuously Insured Person after leaving former employer Notification of Name Change for Voluntarily and Continuously Insured Person

Forms related to benefit

Purpose Title Application form Excel
Word
Example
When you want to reduce the amount of medical care costs you pay at the medical care institution because you expect to incur high medical care costs Certificate of Application of Maximum Copayment Amount
If you paid the entire medical care cost up front because you were unable to present your health insurance card Application Form for Medical Care Expenses (because health insurance card not presented or related reasons)
If you ordered custom prosthetic equipment Application Form for Medical Care Expenses (for prosthetic equipment)
If you ordered prescription eyeglasses or contact lenses Application Form for Medical Care Expenses (for prescription eyewear ・ contact lenses)
Childbirth by insured person/dependent family member Claim for Childbirth and Childcare Lump-sum Grant
First child born to insured person/dependent family member Request for Distribution of Childcare Book
If the insured person is without pay during time off from work for childbirth Claim for Maternity Allowance
If the insured person is without pay during time off from work resulting from illness/injury Application for Injury and Illness Allowance plus Additional Sum ** The application form will be distributed by each company’s HR department prior to start of absence.
If the insured person is without pay during time off from work resulting from illness/injury Status Report submitted at time of first claim ** The application form will be distributed by each company’s HR department prior to start of absence.
If you become sick or injured due to a traffic accident or the actions of another party Notification of Injury or Sickness due to a Third-party Act
If you become sick or injured due to a traffic accident or the actions of another party Written Pledge
To be submitted every six months after an accident until submission of Notice of Completion of Treatment Interim Report on Injury or Sickness due to a Third-party Act
To be submitted promptly following completion of treatment or stabilization of condition after an accident Notice of Completion of Treatment
If you have been in an accident attributable to your own negligence Certificate of Accident Due to Own Negligence
If you received treatment overseas Application Form for Overseas Medical Care Expenses
If you received treatment overseas Attending physician’s statement (Form A)
If you received treatment overseas Attending dentist’s statement (Form C)
If you received treatment overseas Itemized receipt (Form B)
If you received treatment overseas Letter of Consent to Investigation
When your doctor states that transportation is necessary to or between hospitals【For prior approval】 Application Form for Approval of Transportation
When your doctor states that transportation is necessary to or between hospitals【To claim expenses】 Application Form for Transportation Expenses
Death of insured person/dependent family member Claim for Funeral Expenses
If you receive treatment for chronic renal insufficiency or hemophilia requiring dialysis Application Form for Certificate Issued for Specific Disease Treatment
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