Application formsPlease fill in the application form clearly and correctly. If it is not legible, we will return the application form.
The application form is in Japanese only. Please fill out the form in Japanese.
The application form is in Japanese only. Please fill out the form in Japanese.
| Dependent | |
|---|---|
| Dependent Survey Form |
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| Notification of Health Insurance Dependent (Change) |
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| Dependent Certification Pledge |
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| Insurance card | |
| Application Form for Reissue of Health Insurance Card (Card loss/Damage) |
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| Notification of Name Change (Correction) |
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| Application Form relating to Sex Notation of Health Insurance Card |
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| My number (Social Security and Tax Number System) | |
| My Number (Social Security / Tax Number System) Application form to the Health Insurance Association |
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| Benefit | |
| Application Form for Issuance of Maximum Copayment for Health Insurance |
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| Application Form for loss of Maximum Copayment Certificate for Health Insurance |
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| Application Form for issue of Certificates Issued for Specific Disease Treatment |
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| Application Form for Medical Care Expenses (advance payment) |
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| Application Form for Medical Care Expenses (orthotics for treatment/pediatric medical glasses) |
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| Photos of the made orthosis |
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| Confirmation documents for making orthotics |
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| Application Form for Medical Care Expenses (acupuncture) |
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| Application Form for Medical Care Expenses (moxibustion/massage) |
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| Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf) |
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| Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum (not using system of direct payment) |
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| Letter of Consent |
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| Claim for Maternity Allowance |
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| Claim for Injury and Sickness Allowance |
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| Claim for Funeral Expenses |
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| Application Form for Transportation Expenses |
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| Application Form for Overseas Medical Care Expenses |
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| Attending Physician's Statement（Form A) , Japanese translation (Form A-2) |
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| Attending Physician's Statement（Form B) , Japanese translation (Form B-2) |
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| Agreement of Authorization for Overseas Medical Care Expenses |
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| Insured person (dependent person) qualification | |
| Request for Health Insurance Certificate (Certificate of loss of qualification etc) |
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| Notification of Applicability for Long-term Care Insurance Exemption |
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| Notification of Non-applicability for Long-term Care Insurance Exemption |
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| Voluntarily and continuously insurance | |
| Application Form for Certification as Voluntarily and Continuously Insured Person |
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| Notification of Change of Registration Matters for a Voluntarily and Continuously Insured Person |
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| Application Form for Disqualification as Health Insurance Voluntarily and Continuously Insured Person |
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