Application form (For Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person)

Forms related to health insurance cards and eligibility coverage
Forms related to insurance benefits and claims
Forms related to subsidies for health checkups, etc.

Forms related to health insurance cards and eligibility coverage (For Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person)

Name of Application form	Application Form	Example
T-002　Notification of Change (Correction) of Name, Date of Birth, etc. T-011　Notification of Health Insurance Dependent Change (Increase) T-012　Notification of Health Insurance Dependent Change (Removal) T-022　Notification of Change (decrease) of Dependents and Address (For those applicable to the Medical Care System for the Advanced Elderly) T-101　Application Form for Reissue of Health Insurance Card T-501　Notification of Overseas Posting Exempt from Long-term Care Insurance/Return to Japan (for Overseas Residents, etc.)	To authentication page
T-003　Notification of (Change of) Current Address of Insured Person	Application Form	Example
T-005　Notification of Personal Number (My Number)	Application Form	Example
T-013　Notification of status in connection with application for dependents	Documents to attach	Example
T-015　Agreement for recognition of dependents	Documents to attach	Example
T-016　Application for recognition of dependency due to receipt or non-receipt of unemployment benefits	Documents to attach	Example
T-017　Request for certificate of items stated in resident register	Documents to attach	Example
T-018　Request for certificate of employment	Documents to attach	Example
T-102　Notification of non-return of insured person's card for those who lost their eligibility	Application Form	Example
T-103　Notification of Inability to Return Health Insurance Card for bulk updating	Application Form	Example
T-401　Request for Certificate of Eligibility/Loss of Eligibility	Application Form	Example
T-402　Application for issuance of certificate of insurance premium payment	Application Form	Example

Consult with the Operations Dept. (Application) of the Health Insurance Society if you have gender identity disorder and would prefer not to have the name or gender from your family register indicated on your health insurance card.

PAGE TOP

Forms related to insurance benefits and claims (For Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person)

Name of Application form	Application Form	Example
K-601　Application Form for Issuance of Maximum Copayment for Health Insurance	Application Form	Example
K-501　Application for Certification of Benefits	Application Form	Example
K-001　Claim for Medical Care Expenses (Advance Payment, Prosthetic Equipment, etc.) * This application form cannot be used when you have paid the entire cost of medical checkup in advance. Click here when you have paid for the health checkup.	Application Form	Example (advance payment) Example (Use National Health Insurance and other insurance cards ) Example (Prosthetic equipment) Example (Eyeglasses for the treatment of amblyopia in children)
K-002　Detailed receipt (examination and treatment)	Documents to attach	ー
K-002　Detailed receipt (examination and treatment) (Dental)	Documents to attach	ー
K-002　Receipt (dispensing) statement	Documents to attach	ー
K-007　Certificate of instruction to fabricate prosthetic equipment and fitting thereof	Documents to attach	ー
K-008　Prescription for eyeglasses prepared to treat juvenile amblyopia or similar conditions	Documents to attach	ー
K-003　Claim for Medical Care Expenses (for Massage)	Application Form	Example
K-040　Certificate of Medical Care Expenses (Massage)	Documents to attach	ー
K-005　 (Physician’s) Letter of Consent (for Massage)	Documents to attach	ー
K-010　Receipt Submittal Sheet	Documents to attach	ー
K-042　Home Treatment Confirmation Form	Documents to attach	ー
K-004　Claim for Medical Care Expenses (for Acupuncture/Moxibustion)	Application Form	Example
K-041　Certificate of Medical Care Expenses (Acupuncture/Moxibustion)	Documents to attach	ー
K-009　(Physician’s) Letter of Consent (for Acupuncture/Moxibustion)	Documents to attach	ー
K-010　Receipt Submittal Sheet	Documents to attach	ー
K-042　Home Treatment Confirmation Form	Documents to attach	ー
K-011　Application Form for Overseas Medical Care Expenses	Application Form	Example
K-012　Medical Consultation Details（statement）(Dental)	Documents to attach	ー
K-013　Medical Consultation Details（statement）	Documents to attach	ー
K-014　Overseas Medical Care Expenses (Japanese translation)	Documents to attach	ー
K-033　Claim for Childbirth and Childcare Lump-sum Grant	Application Form	Example (If the insured person has given birth) Example (If a dependent has given birth)
K-054　Health Insurance Coverage Survey Form (for application for payment of Childbirth and Childcare Lump-sum Grant)	Documents to attach	ー
K-039　Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf)	Application Form	Example (If the insured person has given birth) Example (If a dependent has given birth)
K-054　Health Insurance Coverage Survey Form (for application for payment of Childbirth and Childcare Lump-sum Grant)	Documents to attach	ー
K-037　Claim for Funeral Expenses/Funeral Costs	Application Form	Example (Death of an insured person) Example (Death of a dependent)
K-038_2　Notification of Succession to Rights (and request for refund)	Application Form	Example
K-021　Application Form for Transportation Expenses	Application Form	Example
K-022　Application Form for Approval of Transportation/ Notification of Transportation	Application Form	Example
K-101　Application Form for issue of Certificates Issued for Specific Disease Treatment	Application Form	Example
K-201　Application form for certification of application of the maximum amount and reduction of the standard burden amount	Application Form	Example
K-006　Request form for medical treatment expenses (for application for payment of the difference in the standard amount for meal treatment expenses)	Application Form	Example
K-401　Application for Loans for Childbirth Expenses	Application Form	Example
K-050　Application form for payment of high-cost combined long-term care treatment cost	Application Form	Example
K-051　Application for payment of high-cost combined long-term care treatment expenses, and application for issuance of a certificate of co-payment	Application Form	Example

Consult with the Operations Dept. (Benefits) of the Health Insurance Society if you have gender identity disorder and have changed the gender or name indicated on your health insurance card and would also prefer to change the corresponding description on the Certificate of Application of Maximum Copayment Amount or other documents.

PAGE TOP

Procedures related to subsidies for health checkups, etc. (For Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person)

Contents	Name of Application form
When you have paid the entire cost of the health checkup in advance.
(1) Employees	Application support system Request for subsidy for health checkups （Connect to Hitachi Group Intranet.）
(1) Employees	If you are unable to use the application support system Request for Subsidy for Health Checkups (Examinations) (for employee individual reimbursements) Example Specific Health Checkup Questionnaire
(2) Family members of employees, and individuals and family members of a Voluntarily and Continuously Insured Person and Special-Case Retired Person	Request for subsidy for health checkups (for family, Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person)(Personal replacement)
When you receive a health checkup at a part-time job, etc.
Family members of employees, and individuals and family members of a Voluntarily and Continuously Insured Person and Special-Case Retired Person	Health examinations guide (Web)

Adobe Reader is required to view and print PDF application documents. If you do not have Adobe Reader, please click the icon on the left to download it.

PAGE TOP