Application forms

Insurance card and application-related forms

Form	Example
Notification of Health Insurance Dependent (Change)(increase) (A4) Notification of Health Insurance Dependent (Change)(increase) (A4)	Example
Notification of Health Insurance Dependent (Change)(deletion) (A4)	Example
Application Form for Reissue of Health Insurance Card (Card loss/Damage) (A4)	Example
Notification of Name Change (Correction) (A4) Notification of Name Change (Correction) (A4)	Example
Written pledge for dependent certification and Dependent Survey Form (A4)	Example
Application Form relating to Sex Notation of Health Insurance Card (A4)	－
Application Form for Certification as Voluntarily and Continuously Insured Person (A4)	Example
Application Form for Disqualification as Health Insurance Voluntarily and Continuously Insured Person (A4)	Example
Nortificarion of Change Regarding Recipient of Voluntary Continuation of Insurance (A4)	Example
Notification of Applicability for Long-term Care Insurance Exemption (A4)	Example
Notification of Non-applicability for Long-term Care Insurance Exemption (A4)	Example
Request for issuance of Maximum Co-payment Certificate for Health Insurance (A4)	Example
Application Form for loss of Maximum Co-payment Certificate for Health Insurance (A4)	Example
Application Form for issue of Certificates Issued for Specific Disease Treatment (A4)	Example
Request for Health Insurance Certificate (A4)	Example
Notification of Address Change of Dependent (A4)	Example
Application Form for Standard Income Amount for elderly healthcare benefit (A4)	Example

Form	Example
Application Form for Medical Care Expenses (advance payment/prosthetic equipment) (A4)	Example
Application Form for Medical Care Expenses (acupuncture) (A4)	Example
Application Form for Medical Care Expenses (moxibustion/massage) (A4)	Example
Claim for Injury and Sickness Allowance (A4)	Example
Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum (using system of direct payment) (A4)	Example
Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum (not using system of direct payment) (A4)	Example
Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf) (A4)	Example
Claim for Maternity Allowance (A4)	Example
Claim for Funeral Expenses (A4)	Example
Application Form for Transportation Expenses (A4)	Example
Complete set of Application Form for Overseas Medical Care Expenses (A4)	Example
Agreement of Authorization (A4)