Application forms

Documents to be submitted to the health insurance association via the company (
Group HR & Administrative Service Department　Social Insurance in charge
)
Documents to be submitted directly to the health insurance association

Documents to be submitted to the health insurance association via the company (Group HR & Administrative Service Department　Social Insurance in charge)

Purpose	Title	Application form	Excel Word	Example
Increase in number of dependents (required for all)	Notification of Dependent（S） <Transfer>	Form	Excel	Example <English>
・Spouse	Survey Form (Form 1)	Form	Excel	Example <English>
・Child (other than newborn)	Survey Form (Form 2)	Form	Excel	Example <English>
・Other than spouse and child	Survey Form (Form 3)	Form	Excel	Example <English>
・Living apart	Allowance Report	Form	Excel	Example
・Also see “Documents to Attach for Dependent Certification” and attach all required documents.
Decrease in number of dependents	Notification of Dependent（S） <Transfer>	Form	Excel	Example <English>
Change/correction of dependent’s name/date of birth	Notification of Change in Dependent Name/Date of Birth	Form	Excel	Example
If the insured person is without pay during time off from work for childbirth	Claim for Maternity Allowance	Form	Excel	Example
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.

Documents to be submitted directly to the health insurance association

Purpose	Title	Application form	Excel Word	Example
Reissuing a lost health insurance card	Request for Reissue of Health Insurance Card	Form	Excel	Example <English>
Unable to return health insurance card, etc.	Notification of Loss of Health Insurance Card	Form	Excel	Example <English>
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	Form	Excel	Example ＜English>
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)	Form	Excel	Example
If you ordered custom prosthetic equipment	Application Form for Medical Care Expenses (for prosthetic equipment)	Form	Excel	Example
If you ordered prescription eyeglasses or contact lenses	Application Form for Medical Care Expenses (for prescription eyewear ･ contact lenses)	Form	Excel	Example
Childbirth by insured person/dependent family member	Claim for Childbirth and Childcare Lump-sum Grant	Form	Excel	Example
First child born to insured person/dependent family member	Request for Distribution of Childcare Book	Form	Word	Example
If you have been in an accident attributable to your own negligence	Certificate of Accident Due to Own Negligence	Form	Excel	Example
If you received treatment overseas	Application Form for Overseas Medical Care Expenses	Form	Excel	Example
If you received treatment overseas	Attending physician’s statement (Form A)	Form	-	-
If you received treatment overseas	Attending dentist’s statement (Form C)	Form	-	-
If you received treatment overseas	Itemized receipt (Form B)	Form	-	-
If you received treatment overseas	Letter of Consent to Investigation	Form	Word	Example
When your doctor states that transportation is necessary to or between hospitals【For prior approval】	Application Form for Approval of Transportation	Form	Excel	Example
When your doctor states that transportation is necessary to or between hospitals【To claim expenses】	Application Form for Transportation Expenses	Form	Excel	Example
Death of insured person/dependent family member	Claim for Funeral Expenses	Form	Excel	Example
If you receive treatment for chronic renal insufficiency or hemophilia requiring dialysis	Application Form for Certificate Issued for Specific Disease Treatment	Form	Excel	Example
Remaining a member of the Health Insurance Association after you leave your employer	Notifications regarding Voluntarily and Continuously Insured Person	Form	Excel	Example
Name change while Voluntarily and Continuously Insured Person after leaving former employer	Notification of Name Change for Voluntarily and Continuously Insured Person	Form	Excel	Example

Application forms

Documents to be submitted to the health insurance association via the company (Group HR & Administrative Service Department Social Insurance in charge)

Documents to be submitted directly to the health insurance association

Documents to be submitted to the health insurance association via the company (Group HR & Administrative Service Department　Social Insurance in charge)