Information on insured person

Request for Payment of Medical Expenses for Insured Person or Dependent[Advance Payment on Behalf of Third Party]
Insurance cardcode and number

Number●●XXXX

Name of affiliatedoffice/department

XXXX Co., Ltd., XXXX Branch
Telephone number (ext.) 03-1234-5678(999）

ケンポ タロウ

Furigana
Name●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo
Address, telephone
number, etc. of applicant(daytime phone number)〒123-4567
XXXX Condominium, #456 1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345Employee ID number

1234567

E-mail address

XXXX＠XXXX.ne.jp

Person undergoing medicaltreatment(circle the applicable person）

Insured person / Family member (dependent)

Name of person
undergoing medicaltreatment

Taro Kempo

Name of injury /illness

Influenza

Date of birth of
person undergoing
medical treatment●● (Y) ●● (M) ●● (D)Cause and progressof symptoms

Application details

CodeI had a high fever and underwent an emergency examination at a hospital while traveling.

Name of medicalinstitution
where examination wasconducted

Period during which
medical treatment
was conducted

From ● (Y) ● (M) ● (D)Cost of medical care

12,000

to ● (Y) ● (M) ● (D)X-X-X-cho, XXXX City,Fukuoka Prefecture

Address of medical institution
where examination wasconducted

XXXX Hospital

If hospitalized during the period● days listed on the left, the period ofFrom(Y)

(M)

(D)

to(Y)

(M)

(D)

days

that hospitalization

yenContent of treatment

Underwent medical treatment andreceived administration of drugs

Reason for claim forpayment of medical care
costs
(Circle the applicablereason)

1. I had just entered the company and had not yet received my insurance card
2. I was not carrying my insurance card, but I was forced to receive care at a medical institution due to sudden illness/injury
3. I used my previous insurance card
4. Other ()Was the need for medicalcare caused by a thirdparty (traffic accident,etc.)?

If the need for medical care
was caused by a thirdparty, please describe thesituation

No / Yes*If you wish to delegate receipt, please complete the authorization letter.

Information ontransfer

Authorization
Letter☑(1) I hereby entrust the receipt of benefits based on this claim to the employer. ← Insert a check (☑) in the box of the applicable item.
□(2) I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

Name

Representative(individual actually receiving benefits)

Name

Name of financial
institution

Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Bank

Central branch

Shinkin bank(credit treasury)

BranchBranch number

Please fill in the section for the authorization letter, except for persons enrolled in voluntary

Savings account
OtherAccountnumberType of account and continuous health insurance
coverageand retirees.
()
Checking accountName of accountholder(Katakana)If you are a person enrolled in voluntary and continuous health insurance coverage or a
[Documents for Attachment]

retiree, please fill in the section for information on transfer destination.

1. Certificate of medical remuneration (original) *If you are unable to attach the receipt, please obtain a physician’s certificate for the second sheet (itemized (medicaltreatment) receipt).
2. Receipt (original copy)

Remarks

Individual number (not required when entering the code and number from the insured person's card)

Date request received(stamp)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.
One of the following: (1) Copy of individual number notification card, (2) Copy of certificate of residence listing individual number, (3) Copy of individual number card (bothsides)
・ When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Works Human Intelligence Health Insurance Society(20210401)

Itemized (Medical Treatment) Receipt (Physician’s Certificate)*Please submit if you are unable to attach the Certificate of medical remuneration.

If you are unable to have the medical institution issue a Certificate of
medical remuneration, please ask the medical institution for a
Itemized (Medical Treatment) Receipt.
Month of medicaltreatment
Actual number of daysof medical treatment

Name of patient

Name of injury / illnesstime(s)pointsDate of hospitalization:time(s)pointsBed Treatment Basic hospitalization fees/additional feestime(s)pointsx

days

pointstime(s)pointsx

days

pointsFollow-up visittime(s)x

days

pointsAdditional fees foroutpatient care

Hospitaliza
pointstiontime(s)pointsx

days

pointstime(s)pointsx

days

pointstime(s)pointstime(s)points

Initial examination
InitialAfter-hours
examinatio
Days offn
Late-night

Follow-up
After-hours
visit
Days off
Late-nightSpecified hospital charges/ Other fees

Medicaladministrat
ion

pointsAt-homepoints

Dietaryhabits

Oral

Single dosepointsTaken only onceSingle dosepoints

Single dosepointstime(s)pointstime(s)pointsAdministra Topicaltion ofPrescription
drugs
Narcotic or
psychotropic agent

Basic dispensing fee
Subcutaneous

pointstime(s)pointstime(s)pointsProcedure Proceduretime(s)pointsSurgical Operation
anesthesia Anesthesia

time(s)pointstime(s)pointstime(s)pointsDiagnostic
imagingtime(s)pointsOthertime(s)points

Other

Test

Test/pathology

yenxtime(s)Specialyenx

time(s)

Diet

yenx

time(s)Environment

yenx

time(s)yenxtime(s)Standardtime(s)xReduction / Exemption / Deferment / I / II / MarchSpecial

yenpointstime(s)Injection IntravenousStandardTotalyen

I hereby certify receipt of the above (medical treatment）.

(Y)

(M)

(D)

Address of medical institution
Name of medical institution

Name of physician
Telephone number of medicalinstitution（）(20210401)