Application forms

Download the appropriate application form.

Health insurance eligibility and application-related forms
Benefit forms

Health insurance eligibility and application-related forms

Form	Example
Notification of Health Insurance Dependent (Change)	Example（increase） Example（decrease）
Dependents' current status sheet (spouse)	Example
Dependents' current status sheet (children)	Example
Dependents' current status sheet (parents)	Example
Dependents' current status sheet (others)	Example
Self-employed person's income declaration form	Example
Health insurance card, elderly benefits card, Certificate of Application of Maximum Copayment Amount loss/damage/reissue application	Example
Notification of Name Change	－
Application form for certificate of eligibility	Example
Application form for Eligibility Verification Certificate	－
Application Form for Certification as Voluntarily and Continuously Insured Person	Example
Notification of loss of eligibility for Voluntarily and Continuously Insured Person	－
Notification of address change of Voluntarily and Continuously Insured Person	－

Benefit forms

Form	Example
Application Form for Medical Care Expenses (prepayment, prosthetics, blood transfusion)	Example（prepayment）
Application Form for Medical Care Expenses (acupuncture, moxicautery)	Example
Application Form for Medical Care Expenses (massage)	Example
Application Form for Medical Care Expenses (overseas)	－
Medical consultation details (Form A)	－
Japanese translation of medical consultation details (Form A)	－
Itemized receipt (Form B)	－
Japanese translation of itemized receipt (Form B)	－
Dental consultation details (Form C)	－
Japanese translation of dental consultation details (Form C)	－
Letter of consent to inquiries by insurer made with medical care institution overseas	－
International Classification of Diseases for social insurance use	－
Application for injury and sickness allowance	Example
Letter of consent	－
Status inquiry form	Example
Application for maternity allowance	Example
Claim for Childbirth and Childcare Lump-sum Grant (when not using system of direct payment)	Example
Claim for Childbirth and Childcare Lump-sum Grant (childbirth overseas) Letter of consent (childbirth overseas)	－
Claim for Childbirth and Childcare Lump-sum Grant (for receipt on your behalf)	Example
Request for issuance of Certificate of Application of Maximum Copayment Amount	Example
Application Form for Certificate Issued for Specific Disease Treatment	Example
East Japan partial copayment waiver application	－
Application Form for Funeral Expenses Additional Sum	Example Example
Online application by health support service “Pep Up” from this year.　（https://pepup.life/petition_projects）	－

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