Application Forms
Application Forms
Forms Related to Application, a Health Insurance Card and an Eligibility Confirmation Document
| No | Application name | Document | EXAMPLE | Document submission destination | |
| Health Insurance Notification of Change of Covered Dependents (Addition) | PDF |
EXCEL |
EXAMPLE |
Works Human Intelligence Human Resources |
|
| Dependent certification record | PDF |
EXCEL |
－ | ||
| Written Oath in Regard to Dependent Certification | PDF |
EXCEL |
－ | ||
| Certificate of Conditions of Employment | PDF |
EXCEL |
－ | ||
| Health Insurance Notification of Change of Covered Dependents (Removal) | PDF |
EXCEL |
EXAMPLE |
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| Date of Acquisition/Loss of Qualification as an Insured Person Date of Certification/Deletion as a Dependent Voluntary Continuation of Insurance Premium Payment | PDF |
EXCEL |
－ | ||
| Application for Reissuance of Health Insurance Card, Eligibility Confirmation Document or Elderly Beneficiary Health Insurance Card Due to Loss/Damage | PDF |
EXCEL |
EXAMPLE |
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| Application for (Re)issuance of Eligibility Confirmation Document | PDF |
－ | － | ||
| Application form for canceling registration of the use of Individual Number Card as a Health Insurance card | PDF |
－ | － | ||
| Request for Issue of Health Insurance Eligibility Certificate for Ceiling-Amount Application Form | PDF |
EXCEL |
EXAMPLE |
Works Human Intelligence Health Insurance Society Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051 |
|
| Health Insurance Request for Issuance of Certificate Issued for Specific Disease Treatment Application Form | PDF |
EXCEL |
EXAMPLE |
||
| Written Notice for Acquisition of Qualification as a Voluntarily and Continuously Insured Person | PDF |
EXCEL |
EXAMPLE |
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| Written Notice for Loss of Qualification as a Voluntarily and Continuously Insured Person | PDF |
EXCEL |
EXAMPLE |
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1～9
Document submission destination
Document submission destination
Works Human Intelligence Human Resources
10～13
Document submission destination
Document submission destination
Works Human Intelligence Health Insurance Society
Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051
Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051
Benefits
| No | Application name | Document | EXAMPLE | Document submission destination | |
| Injury and Sickness Benefits Application | PDF |
EXCEL |
EXAMPLE |
Works Human Intelligence Human Resources |
|
| Certificate of Consent | PDF |
WORD |
－ | ||
| Request for Payment of Maternity Allowance | PDF |
EXCEL |
EXAMPLE |
||
| Claim for Health Insurance Payment of Funeral Expenses (Costs) additional benefits | PDF |
EXCEL |
EXAMPLE |
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| The Childbirth and Childcare Lump-Sum Grant additional benefits [If not using the system of direct payment to medical institutions, or if childbirth took place outside of Japan] |
PDF |
EXCEL |
EXAMPLE |
Works Human Intelligence Health Insurance Society Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051 |
|
| The Childbirth and Childcare Lump-Sum Grant additional benefits [System of receipt of the Childbirth and Childcare Lump-sum Grant directly by the medical institutions on your behalf] |
PDF |
EXCEL |
EXAMPLE |
||
| Request for Payment of Medical Expenses [Advance Payment on Behalf of Third Party] | PDF |
EXCEL |
EXAMPLE |
||
| Request for Payment of Medical Expenses [for therapeutic devices, therapeutic eye glasses, etc.] | PDF |
EXCEL |
EXAMPLE |
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| Regarding Photographs of Therapeutic Devices | PDF |
EXCEL |
－ | ||
| Request for Payment of Medical Expenses [for acupuncture and moxibustion] |
PDF |
EXCEL |
EXAMPLE |
||
| Request for Payment of Medical Expenses [for massages] | PDF |
EXCEL |
EXAMPLE |
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| Application for Health Insurance Payment of Medical Care Costs [for overseas medical expenses] |
PDF |
EXCEL |
EXAMPLE |
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| Attending Physician's Statement [Form A] |
PDF |
EXCEL |
－ | ||
| Itemized Receipt [Form B] | PDF |
EXCEL |
－ | ||
| Attending Physician Statement | PDF |
EXCEL |
－ | ||
| Agreement of Authorization | PDF |
WORD |
－ | ||
14～17
Document
submission
destination
Document
submission
destination
Works Human Intelligence Human Resources
18～29
Document submission
destination
Document submission
destination
Works Human Intelligence Health Insurance Society
Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051
Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051
保健事業関係
| No | Application name | Document | EXAMPLE | Document submission destination | |
| インフルエンザ予防接種費用 補助金支給申請書 |
Click here | Works Human Intelligence Health Insurance Society Yoyogi East Building 8F, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051 |
|||
| 健診費用補助金支給申請書 （契約外医療機関） |
PDF |
－ | － | ||
30～31
Document submission destination
Document submission destination
Works Human Intelligence
Health Insurance Society
5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051
Health Insurance Society
5-23-5 Sendagaya, Shibuya-ku, Tokyo, 〒151-0051