Request for Payment of Medical Expenses for Insured Person or Dependent

Information on insured person/Application
details[for acupuncture and moxibustion]
CodeInsurance cardcode and number

NumberName of affiliatedoffice/department

Furigana

Name of insured
personAddress,
telephone number, etc.
(daytime phone number)Phone number

(Y)

(M)

(D)

(Y)

(M)

(D)

〒
E-mail address
Date of birth ofperson
who received

Cause of illness
or injury

Was the need for medicalcare caused by a third party(traffic accident, etc.)?

Telephone number()

Date of first medical care
(M)

No / Yes

Procedures period(D) From(Y)1. Neuralgia

Name of injury /illness)

Date of birthof insured person

Name of person
who received
medical care

(Y)

(Ext.

(M)

(D)

2. Rheumatism

5. Lower back pain

to(Y)

(M)

3. Cervicobrachial syndrome

6. Cervical sprain (whiplash)

Actual numberof days

Claim classificationdays

New / Continuation(D)

4. Shoulder periarthritis (frozenshoulder)

Outcome)Continuation / Cured / Discontinued /Transfer to a different practitioner

7. Other (2. Acupuncture (combined use of
4. Moxibustion (combined use of electric heat
3. Moxibustion
electroacupuncture)therapy device)
5. Combination of acupuncture and6. Combination of acupuncture and moxibustion (combined use of electroacupuncture and electric heatmoxibustion
therapy device)

1. Acupuncture

Procedure column

First time
Acupuncture

yenxtime(s) =yen

Acupuncture (combined use of electroacupuncture)

yenxtime(s) =yenSecond and Moxibustion
subsequent
procedures Moxibustion (combined use of electric heat therapy device)yenxtime(s) =yenyenxtime(s) =yenCombination of acupuncture and moxibustion

yenxtime(s) =yenCombination of acupuncture and moxibustion (combined use ofelectroacupuncture and electric heat therapy device)yenxtime(s) =yenHouse call fee

Up to 4 ｋm

yenxtime(s) =yenHouse call fee

Up to 4 ｋm

yenxtime(s) =yenyenxtime(s) =yenFees for issuing treatment report (Previously paid for date: (Month/Year))
Total amount of costs
Date of procedure
Visit to thepractice: 〇House call: ◎Monthyen

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Health center registration
classification

Record of Remarksconsent

Treatment
certificate

Procedures were carried out as shown above and related fees were received.

(Y)

Summary(M)1. Address of clinic

2. Address of professional practitioner making a house-call, etc.

(D)

Registration code number (registration number of reportedpractitioner)＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

ClinicClinic manager

Name of consenting physician

Address
Name
Name

Address

Phone number

Date of consent
(Y)

(M)

Name of injury / illness

Period requiring
medical care(D)*If you wish to delegate receipt, please complete the authorization letter.

Remarks

Information ontransfer destination

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

Savings accountType of accountChecking account

Other()

Date:

(Y)

(M)

Bank

Central branch

Shinkin bank(credit treasury)

BranchAccount number(D)Branch number
Name of accountholder(Katakana)

Individual number (not required when entering the code and number from the insured person's card)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.

Date request received(stamp)

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 (both sides)
・ 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)