Information on insured person

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

NumberName of affiliatedoffice/department

Phone number

(Ext.

)

Furigana
Name
Address, telephone
number, etc. of applicant(daytime phone number)

Date of birth

(M)

(D)

〒
Phone number

Employee ID
number
Person undergoing medicaltreatment(circle the applicable person）

(Y)

(Ext.

)

E-mail address
Name of person
Insured person / Family member (dependent) undergoing medicaltreatment
Date of birth of
person undergoing
medical treatment

Name of injury /illness

(Y)

(M)

(D)

Application details

Cause and progressof symptoms
Name of medicalinstitution
where examination wasconducted

Address of medical institution
where examination wasconducted

Period during which
medical treatment
was conducted

From

(Y)

(M)

(D)

days
to(Y)

(M)

(D)

Cost of medical careyen

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

If hospitalized during theperiod listed on the left, theperiod of that hospitalization

From(Y)

(M)

(D)

to(Y)

(M)(D)

days

Content of treatment

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 medicalcare was caused by a third
party, 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

Savings accountType of accountChecking account

Other()

Date:(Y)BankCentral branch

Shinkin bank(credit treasury)

BranchAccount number(M)(D)

Branch number
Name of accountholder(Katakana)[Documents for Attachment]
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
(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)

Itemized (Medical Treatment) Receipt (Physician’s Certificate)*Please submit if you are unable to attach the certificate of medical remuneration.
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)pointsLate-nighttime(s)pointsFollow-up visittime(s)pointsAdditional fees foroutpatient caretime(s)

Initial examination
InitialAfter-hours
examinatio
Days offn

Follow-up
After-hours
visit
Days offx

days

pointsx

days

pointsx

days

pointspointsx

days

pointstime(s)pointsx

days

pointstime(s)pointstime(s)pointsHospitaliz
ation

Specified hospital charges/ Other fees
Late-night
Medicaladministration

pointsAt-homepoints

Dietaryhabits

Oral

Single dosepointsTaken only onceSingle dosepointsAdministr Topicalation ofdrugs Prescription
Narcotic or
psychotropic agent

Single dose

Subcutaneous

pointstime(s)pointspointstime(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

xtime(s)Specialyenxtime(s)Dietyenxtime(s)Environment

yenxtime(s)yenxtime(s)Standard
Specialyenpointstime(s)Injection Intravenousyentime(s)xpoints Reduction / Exemption / Deferment / I / II / Marchtime(s)Basic dispensing fee

StandardTotal

yenI 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)