* Only Japanese version available
- Insurance card and application-related forms
- Benefit and claims-related forms
- Health activities-related forms
Insurance card and application-related forms
Adding a family member, or removing a family member
If you lose or damage your health insurance card
| No. | form | example |
|---|---|---|
| 5 | Application Form for Reissue of Health Insurance Card (Card loss/Damage) | Example |
If the name has changed
| No. | form | example |
|---|---|---|
| 6 | Notification of Name Change of Insured Person (Family) | Example |
If you wish to remain a member of the Health Insurance Society after you leave your employer
| No. | form | example |
|---|---|---|
| 7 | Application Form for Certification as Voluntarily and Continuously Insured Person | Example |
If you lose eligibility as a Voluntarily and Continuously Insured Person
| No. | form | example |
|---|---|---|
| 8 | Notification of Loss of Eligibility as Voluntarily and Continuously Insured Person | Example |
When you are exempt from the long-term care insurance program
Benefit and claims-related forms
If you take time off from work due to sickness or injury
| No. | form | example |
|---|---|---|
| 10 | Application for Payment of Injury and Illness Allowance | Example |
If you paid the entire medical care cost up front
| No. | form | example |
|---|---|---|
| 11 | Application Form for Medical Care Expenses | Example |
| 12 | Application Form for Medical Care Expenses (Acupuncture, Moxibustion) | |
| 13 | Application Form for Medical Care Expenses (Massage, Shiatsu) | |
| 14 | About photo of therapeutic equipment | |
| 15 | Attending physician's statement (Overseas)
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|
| 16 | Attending physician's statement (Dental) |
If there is an unavoidable emergency transfer due to difficulty moving as a result of an sickness or injury
| No. | form | example |
|---|---|---|
| 17 | Application Form for Transportation Expenses | Example |
Childbirth
If you take time off from work for childbirth
| No. | form | example |
|---|---|---|
| 20 | Application for Payment of Maternity Allowance | Example |
Death
| No. | form | example |
|---|---|---|
| 21 | Application for Payment of Funeral Expenses | Example |
| 22 | Notification of Succession of Rights |
When you incur high medical care costs
| No. | form | example |
|---|---|---|
| 23 | Request for issuance of Maximum Co-payment Certificate for Health Insurance | Example |
| 24 | Application for Payment of In-home Care Support | Example |
If you receive treatment for chronic nephritis that require artificial dialysis or haemophilia
| No. | form | example |
|---|---|---|
| 25 | Application for Certificate of Treatment for Specified Diseases and Disorders | Example |