Request for Payment of Medical Expenses for Insured Person or Dependent
Information on insured person[for therapeutic devices, therapeutic eye glasses, etc.]
CodeInsurance cardcode and number

NumberName of affiliatedoffice/department

Phone number

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

Date of birth

(Y)

(M)

(D)

(M)

(D)

〒
Phone number

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

(Ext.

)

E-mail address

Insured person / Family member (dependent)

Name of person
undergoing medicaltreatment
Date of birth of
person undergoing
medical treatment

Name of injury /illness
Cause and progressof symptoms

Application details(Ext.

Furigana(Y)

Date of injury
or onset of illness

Name of medical
institution where
examination wasconducted

(Y)

(M)

(D)

Address of medical
institution whereexamination wasconducted

FromPeriod during which
medical treatment wasconducted

(Y)

(M)

(D)

If hospitalized during theFrom(Y)

(M)

(D)

to(Y)

(M)

(D)

days period listed on the left, theto(Y)(M)

Cost of therapeutic
devices, etc.

yen

Date of attaching
therapeutic devices,etc.

1. Wearing of therapeutic devices, etc.
2. Creation of therapeutic eye glasses, etc.
3. Other (Content oftreatment
Was the need for medicalcare caused by a thirdparty (traffic accident,etc.)?

days

period of that hospitalization

(D)

(Y)

(M)

(D))
If the need for medicalcare was caused by a thirdparty, please describe thesituation

No / Yes*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

Name of financial
institution
Type of account

Savings accountChecking account

Other()

Date:

(Y)

Bank

Central branch

Shinkin bank(credit treasury)

Branch(M)(D)

Branch number
Name ofaccount holder(Katakana)

Account number■ Documents for Attachment[For Therapeutic Devices][For Therapeutic Eye Glasses, etc.]

1. Physician's certificate, instructions, or written diagnosis (original copy)

1. Physician’s written instructions for creation of therapeutic eye glasses, etc.

2. Receipt (original copy)

2. Patient examination/test results

3. Written document confirming wearing of the device (photograph of the created device)

3. 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)