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) (A4 Landscape)	(increase) Example (decrease) Example
Dependents' current status sheet (spouse) (A4 Portrait)	Example
Dependents' current status sheet (children) (A4 Portrait)	Example
Dependents' current status sheet (parents) (A4 Portrait)	Example
Dependents' current status sheet (others) (A4 Portrait)	Example
Self-employed person's income declaration form (A4 Portrait)	Example （A4）
Written Pledge Form for Receiving Unemployment Insurance Benefits (A4 Portrait)	Example （A4）
Health insurance card, elderly benefits card, Certificate of Application of Maximum Copayment Amount loss/damage/reissue application (A4 Portrait)	Example （A4）
Notification of Name Change (A4 Landscape)	－
Application form for certificate of eligibility (A4 Portrait)	Example （A4）
Application form for Health Insurance Eligibility Certificate (A4 Portrait)	－
Application Form for Certification as Voluntarily and Continuously Insured Person (A4 Portrait)	Example （A4）
Notification of loss of eligibility for Voluntarily and Continuously Insured Person (A4 Portrait)	－
Notification of address change of Voluntarily and Continuously Insured Person (A4 Portrait)	－

Benefit forms

Form	Example
Application Form for Medical Care Expenses (prepayment, prosthetics, blood transfusion) （A4）	Example（prepayment）（A4）
Application Form for Medical Care Expenses (acupuncture, moxicautery) （A4）	Example （A4）
Application Form for Medical Care Expenses (massage) （A4）	Example （A4）
Application Form for Medical Care Expenses (overseas) （A4）	－
Medical consultation details (Form A) （A4）	－
Japanese translation of medical consultation details (Form A) （A4）	－
Itemized receipt (Form B) （A4）	－
Japanese translation of itemized receipt (Form B) （A4）	－
Dental consultation details (Form C) （A4）	－
Japanese translation of dental consultation details (Form C) （A4）	－
Letter of consent to inquiries by insurer made with medical care institution overseas （A4）	－
International Classification of Diseases for social insurance use （A4）	－
Application for injury and sickness allowance （A4）	Example （A4）
Letter of consent （A4）	－
Status inquiry form （A4）	Example （A4）
Application for maternity allowance （A4）	Example （A4）
Claim for Childbirth and Childcare Lump-sum Grant (when not using system of direct payment) （A4）	Example （A4）
Claim for Childbirth and Childcare Lump-sum Grant (childbirth overseas) （A4） Letter of consent (childbirth overseas) （A4）	－
Claim for Childbirth and Childcare Lump-sum Grant (for receipt on your behalf) （A4）	Example （A4）
Request for issuance of Certificate of Application of Maximum Copayment Amount （A4）	Example （A4）
Application Form for Certificate Issued for Specific Disease Treatment （A4）	Example （A4）
East Japan partial copayment waiver application （A4）	－
Application Form for Funeral Expenses Additional Sum （A4）	Example （A4） Example （A4）
Please refer to this for the application for influenza vaccination subsidy.	－

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