Information on insured person/Application
details

Request for Payment of Medical Expenses for Insured Person or Dependent[for massages]
Code

Insurance cardcode and number

NumberName of affiliatedoffice/department

Furigana

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

Date of birthof insured person

(Y)

(M)

(D)

(M)

(D)

〒
Telephone number()

E-mail address

Name of person
who received
medical care

Date of birth of person
who received
medical care

(Y)

Cause of illnessor injury

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

No / Yes

Date of first medical care
(Y)

(M)

Procedures period(D)From(Y)

(M)

(D)

to(Y)

(M)

Actual numberof days

Claim classificationdays

New / Continuation(D)

OutcomeProcedure column

Name of injury/illness or
symptomContinuation / Cured / Discontinued /Transfer to a different practitioner
Trunk

yenx

time(s) =yen

Right upperlimb

yenxtime(s) =yen

Left upper limb

yenxtime(s) =yen

Right lowerlimb

yenxtime(s) =yenLeft lower limbyenxtime(s) =yenCorrection of structural deformities

yenxtime(s) =yen

Hot fomentation

yenxtime(s) =yen

Hot fomentation / electro therapy device

yenxtime(s) =yenyenxtime(s) =yenyenyen

MassageUp to 4 ｋm

House call fee
House call fee

More than 4 ｋm

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

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

(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

AddressName
Name

Phone number

Record ofconsent

Remarks

Treatment
certificate)

Name of consenting physician

Address

Date of consent

Name of injury / illness

Period requiring medicalcare

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

Name of financial
institution

Savings accountType of accountChecking account

Other()

Date:(Y)

(M)

Bank

Central branch

Shinkin bank(credit treasury)

BranchAccount number

Branch number
Name of accountholder(Katakana)

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

Remarks(D)*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 (bothsides)
・ When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Date request received(stamp)Works Human Intelligence Health Insurance Society(20210401)