Request for Payment of Medical Expenses for Insured Person or Dependent

Information on insured person[for acupuncture and moxibustion]
Insurance cardcode and number

CodeNumber●●XXXX

Furigana

Name of insured
personXXXX Co., Ltd., XXXX Branch

Name of affiliatedoffice/department

Telephone number (ext.) 03-1234-5678(999）●● (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
E-mail address
XXXX＠XXXX.ne.jp

Phone number: 090-7891-2345

Name of person whoreceived medical care

Hanako Kempo

Date of birth of person
who received medical care●● (Y) ●● (M) ●● (D)Cause of illness
or injury

Joints are swollen and painful

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

No / Yes

Date of first medical care
(Y)

(M)

Name of injury /illness

Procedures period

(D)

From

(Y)

(M)

(D)

to(Y)

(M)

1. Neuralgia

2. Rheumatism

3. Cervicobrachial syndrome

5. Lower back pain

6. Cervical sprain (whiplash)7. Other (Actual numberof days

Claim classificationdays

New / Continuation(D)

4. Shoulder periarthritis (frozenshoulder)

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

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
Acupunctureyenxtime(s) =yen

Acupuncture (combined use of electroacupuncture)yenxtime(s) =yenSecond and Moxibustion
subsequent
procedures Moxibustion (combined use of electric heat therapy device)yen

xtime(s) =yenyenxtime(s) =yenCombination of acupuncture and moxibustion

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

xtime(s) =

yen

yen

xtime(s) =yen

Up to 4 ｋm

House call feextime(s) =Ask the acupunctureyen/ moxibustion
Fees for issuing treatment reportyen x
practitioner to fill thisspacetime(s)out.=Total amount of costs
Up to 4 ｋm

House call fee(Previously paid for date:

Date of procedure
Visit to thepractice: 〇House call: ◎Monthyenyen

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

1. Address of clinic

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

(D)

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

ClinicClinic manager

AddressName
Name

Phone number

Record ofconsent

Remarks

Treatment
certificate(M)yen(Month/Year))

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

(Y)

Summary

Name of consenting physician

Address

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.

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

Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Central branch
Bank
Name of financial
ShinkinbankPleasefillinthesectionfor
theauthorization
letter,exceptfor
persons
enrolled
ininstitution
BranchType of accountName of accountholder()accountenrolled(Katakana) or aIf youChecking
are a person
in voluntary and continuous health insurance coverage

Savings
accountvoluntaryandcontinuousOther
health insurance coverage and retirees.
Account number

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

Remarks

Branch number(credit treasury)

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

*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)