Information on insured person/Application
details

Request for Payment of Medical Expenses for Insured Person or Dependent[for massages]
Insurance cardcode and number

CodeNumber●●XXXX●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo〒123-4567
Address,telephone number, etc.
XXXX Condominium, #456
(daytime phone number)

1-2-3 XXXX-cho, XXXX Ward, Tokyo

Phone number: 090-7891-2345

E-mail address

Name of person
who received
medical care

Hanako Kempo

Date of birth of person
who received
medical care

Cause of illnessor injurySequela due to cerebral
hemorrhage

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

Date of first medical care
(Y)

(M)

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

ケンポ タロウ

Furigana

Name of insured
personName of affiliatedoffice/department

XXXX＠XXXX.ne.jp●● (Y) ●● (M) ●● (D)No / Yes

Procedures period

(D)

From

(Y)

(M)

(D)

to(Y)

(M)

Actual numberof days

Claim classificationdays

New / Continuation(D)

OutcomeName of injury/illness orsymptomContinuation / Cured / Discontinued /Transfer to a different practitioner

yen

Procedure column

TrunkMassage

Correction of structural deformities

Hot fomentation

Right upperlimb
Left upper limb

time(s) =

yen

yenx

time(s) =

yen

yenx

time(s) =

yen
yen
yen

Right lower
limb

yenx

time(s) =Left lower limb

yenx

time(s) =time(s) =x
Ask the masseuse yen
to fillthis space out.

yen

yenx

time(s) =

yen

yenx

time(s) =

yen

yenx

time(s) =

yen
yen
yen

Hot fomentation / electro therapy device
Up to 4 ｋm

House call feex

House call fee

More than 4 ｋm

yenxtime(s) =Fees for issuingtreatment report(Previously paid fordate: (Month/Year))yenxtime(s) =Total
Date of procedure
Visit to thepractice: 〇House call: ◎yenMonth1 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

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)

Clinic＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

Phone number

Record ofconsent

Remarks

Clinic manager

AddressName
Name

Name of consenting physician

Address

Date of consent

Name of injury / illness

Period requiring medical
care

Date:

*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

Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Please fill in the section for the authorization letter, except for persons enrolledCentral
in branchBank
Name of financial
Shinkin bankinstitution voluntary and continuous health insurance
coverage and retirees.
(credit treasury)

Branch number
BranchName of accountholder()Checking accountor a retiree, please fill in the section for information on transfer destination. (Katakana)

Savings
account
If you area person
enrolledOtherin voluntary and continuous health insurance coverage

Type of account

Account number

Remarks

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)