Application forms (for members)

 

Reference link

• How to submit

• Health insurance eligibility and application-related forms
• Benefit and claims-related forms
• Traffic accidents, etc. (documents related to Notification of Injury or Sickness due to a Third-party Act)-related forms

Health insurance eligibility and application-related forms

Related to procedures for dependents

Adding a family member, Removing a family member	1	Notification of Health Insurance Dependent (Change) Example
	2	Notification of Present Situation (Insured Person / Dependent) Example
	3	Written petition of application for dependent
	4	Certificate of salary/wage/etc. payment * If the dependent applicant has employment income and it is not possible to obtain proof of income from the place of employment
	5	Joint Married Couple Support Income Amount Confirmation Table * If you (the insured person) take one month of childcare leave or more, please obtain proof of your spouse’s place of employment.

Related to reissuance of Health Insurance Eligibility Certificate

To have a Health Insurance Eligibility Certificate issued or reissued	6	Application Form for Issue/Reissue of Health Insurance Eligibility Certificate ●If a Health Insurance Eligibility Certificate has been issued Notification of Health Insurance Eligibility Certificate Loss Example
To have the Notice of Eligibility Information reissued	7	Application Form for Reissue of Notice of Eligibility Information

Related to address change

Address changes	8	Notification of Change of Address Example (Please see the example of entering the submission address.) * Before submitting anything, be sure to check the information here.

Related to Application for Eligibility Certificate

If you need an enrollment-period certificate (a Disqualification Certificate, etc.)	9	Application for Health Insurance Eligibility Certificate Example

Related to Voluntarily and Continuously Insured Person

If you wish to remain a member of the Health Insurance Organization when you leave your employer	10	Application Form for Certification as Voluntarily and Continuously Insured Person Example
	11	Pledge * Attach to Application Form for Certification as Voluntarily and Continuously Insured Person
If you wish to add or remove a family member from voluntary and continuous coverage as a dependent	12	Notification of Health Insurance Dependent (Change) for voluntarily and continuously insured persons Example
If the name, address, or bank account of a voluntarily and continuously insured person has changed	13	Notification of Change to Voluntarily and Continuously Insured Person’s Name/Address/Bank Account

Benefit and claims-related forms

Related to the Certificate of Application of Maximum Copayment Amount

If you need the Certificate of Application of Maximum Copayment Amount (When you want to reduce the amount of medical care costs you pay at the medical care institution)	14	Application Form for Issue of Certificate of Application of Maximum Copayment Amount and Standard Copayment Reduction of Maximum Copayment Example
If you lose your Certificate of Application of Maximum Copayment Amount	15	Application Form for Reissuance of Certificates (Loss/Damage Notification) Example

Related to Injury and Sickness Allowance

If you take time off from work due to sickness (if certain conditions are satisfied)	16	Claim for Injury and Sickness Allowance Example
If you take time off from work due to treatment of the sickness or injury (if certain conditions are satisfied)	17	Claim for Injury and Sickness Allowance (For Those Who Have Lost Eligibility) Daily Life and Medical Treatment Status Report for Injury and Sickness Allowance Example

Related to Medical Care Expenses (Up front)

If you paid the entire medical care cost up front (if you received an examination without an insurance card due to a sudden illness, or medical care costs were refunded to your previous health insurance organization, etc.)	18	Application Form for Medical Care Expenses (Charges forward) Example * An application form is necessary for each "examinee", "month", "medical care institution", or "dispensing pharmacy".
	19	Receipt (Medical) Statement (Hospitalization) * This is not necessary if a statement, etc. has been issued to you by a medical care institution.
	20	Receipt (Medical) Statement (Outpatient) * This is not necessary if a statement, etc. has been issued to you by a medical care institution.
	21	Receipt (Medical) Statement (Dental) * This is not necessary if a statement, etc. has been issued to you by a medical care institution.
	22	Receipt (Medical) Statement (Dispensing) * This is not necessary if a statement, etc. has been issued to you by a medical care institution.
If you had a medical orthosis, treatment glasses for children, etc. created	23	Application Form for Medical Care Expenses(Therapeutic equipment) Example
	24	Therapeutic Equipment: Photo Pasting Mount Example * If a lower extremity (foot) orthosis was created
If you underwent acupuncture, moxibustion	25	(Treatment performed before September 30, 2024) Application Form for Medical Care Expenses (for Acupuncture or Moxibustion) Example
		(Treatment performed after October 1, 2024) Application Form for Medical Care Expenses (for Acupuncture or Moxibustion) Example
If you underwent massage, or shiatsu	26	(Treatment performed before September 30, 2024) Application Form for Medical Care Expenses (for Massage, or Shiatsu) Example
		(Treatment performed after October 1, 2024) Application Form for Medical Care Expenses (for Massage, or Shiatsu) Example
If you have transportation expenses of bone marrow or organ transplants	27	Application Form for Medical Care Expenses Related to transplant Example
If you become sick or are injured overseas (if medical consultation and treatment were provided in Japan)	28	[Medical] Application Form Form for Overseas Medical Care Expenses, Attending physician's statement, Itemized receipt
	29	[Medical] Application Form for Overseas Medical Care Expenses, Attending physician's statement, Itemized receipt *Attachments Only English documents needed.
	30	[Dental] Application Form for Overseas Medical Care Expenses, Attending Dentist's statement, Itemized receipt
	31	[Dental] Application Form for Overseas Medical Care Expenses, Attending Dentist's statement, Itemized receipt *Attachments Only English documents needed.
	32	Agreement of Authorization * This must be submitted in the case of both medical and dental care.

Related to Childbirth

If you take time off from work for childbirth	33	Claim for Maternity Allowance Example
Childbirth	34	Claim for Childbirth and Childcare Lump-sum Grant Example
	35	Application Form for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf) Example
	36	Letter of Consent (for a childbirth overseas)

Related to Other Benefits

Death	37	Claim for Funeral Expenses Example
When the total copayments for medical care and long-term care received for the one-year period starting in August of every year exceeded the base amount	38	Application for Payment of High Aggregate Cost for Long-Term Care Service and Issuance of Copayment Certificate
If transportation was necessary for treatment, and such transportation was extremely difficult due to the illness or injury (if the conditions are satisfied)	39	Application Form for Approval of Transportation Expenses / Notification of Transportation Example
	40	Application Form for Transportation Expenses Example
If you wish to apply for the amount difference exceeding the inpatient meal standard expenses during hospitalization	41	Application Form for Difference Payment of Health Insurance Inpatient Meal Standard Expenses Example

Related to Other Procedures

If you wish to apply for benefits due to a traumatic injury	42	Inquiry Regarding Cause of Illness or Injury (Reply) Example
If you have receiving medical expense subsidies from country or local government (municipalities)	43	Medical Expense Subsidy System Notification Form Example(Application) Example(End) * Be sure to attach Copy of the “medical care certificate” issued by municipalities
If you wish to have your list of annual medical care costs issued	44	Request Form for Issue of Medical Care Cost Notice (Medical Care Cost Information) Example
If you will receive high-cost, long-term treatment, including haemophilia, artificial dialysis, etc.	45	Application Form for Issue of Certificates Issued for Specific Disease Treatment Example

Traffic accidents, etc. (documents related to Notification of Injury or Sickness due to a Third-party Act)-related forms

Related to Injury or Sickness due to a Third-party Act

Traffic accidents (Where another party is involved)	46	Notification of Injury or Sickness due to a Third-party Act
Traffic accidents (Where no other party is involved)	47	Notification of an Injury or Sickness due to a Single-car Accident
Non-traffic Accidents	48	Notification of Injury or Sickness due to a Third-party Act
Hit-And-Run, Etc., if Other Party Is Unknown	49	Pledge

• * If you are injured in a traffic accident or by a Third-party act, please call to consult the Health Insurance Organization before submitting your My Number Card as your Health Insurance Certificate to the hospital.