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

Number●●XXXX

Furigana

XXXX Co., Ltd., XXXX Branch

Name of affiliatedoffice/department

Telephone number (ext.) 03-1234-5678(999）

ケンポ タロウ

Name●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo
Address, telephone number,etc. of applicant(daytime phone number)〒123-4567
XXXX Condominium, #456 1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

Employee ID number

1234567

E-mail address

XXXX＠XXXX.ne.jp

Person undergoing medicaltreatment(circle the applicable person）

Insured person / Family member (dependent)

Name of person
undergoing medicaltreatment

Hanako Kempo

Fracture of upper right humerus

Date of birth of
person undergoing
medical treatment

Name of injury /illness
Cause and progress ofsymptoms

Application details

Code●● (Y) ●● (M) ●● (D)Date of injury
or onset of illness

Fell down stairs at home and fractured humerus

Name of medical institution
where examination wasconducted

From ● (Y) ● (M) ● (D)Period during which
medical treatment wasconducted

Address of medical
institution where
examination was conducted

XXXX Hospitalto ● (Y) ● (M) ● (D)Cost of therapeuticdevices, etc.

28,000Content of treatment

If hospitalized during the period

left, the period of that● days listed on thehospitalizationyen

X-X-X-cho, XXXX City,
Fukuoka Prefecture
From(Y)

(M)

(D)

to(Y)

(M)

(D)

days

Date of attaching
therapeutic devices,etc.

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

●● (Y) ●● (M) ●● (D)● (Y) ● (M) ● (D))
If the need for medical care
was caused by a third party,
please describe the situation

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

Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Please fill in the section for the authorization
letter, except for persons enrolled
inCentral branchBank
Shinkin bankvoluntary and continuous health insurance
coverage and retirees.
(credit treasury)

Branch number
BranchName of accountType of account

Savings
Otherin voluntary and continuous health insurance coverage or a
If youare a accountperson enrolled
Account numberholder()Checking accountretiree, please fill in the section for information on transfer destination. (Katakana)■ 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)