Messrs. Bosch Health Insurance Society,Brain Dock (Medical Exam of Brain) Subsidy Bill
【Applicant（Insured Person）】
Insurance
Card

Date: (M)

Symbol(D)ド, (Y)

Insured Person’sName

No.

Contact Phone No.

Site Name（Company Name）

Unit Name－／【Examination Status】
Date of Examination
(M)

(D)

Name of Medical Institution

Yen, (Y)【Conditions for
Payment of Subsidy】
1.
2.
3.
4.
5.
6.

7.
8.

Object person: Insured person of Bosch Health Insurance Society (35 years orolder)
Object period: Every year from April 1 to March 31 of the following yearNumber of applications: Up to once a year
Subsidy amount: See the Bosch Health Insurance Society website.
Application method: The subsidy bill + an original receipt + a copy of medical
examination result are requested to be presented to this Health InsuranceSociety. (The document cannot be returned.)
Receipt entry items: Name of examinee, date of examination, name of medical
institution (seal), unit price, and clear definition that the concerned cost is "thecost of brain dock examination".
※An applicable case is when examined by MRI or MRA. CT examination
alone is not applicable.
Note) We accept the receipt, even if it is of a receipt type slip, as long as
above-mentioned essential entry items are described and together with thereceipt seal of the medical institution. (All the descriptions shall be filled at themedical institutions.)
Cases where you are not eligible for payment:① When the health insurance card was used
Limited to the examination conducted by a medical institution in Japan.

【Where to send
Application】【Recommended
sending method】

Expense※Please don’t fill in here.

Bosch Health Insurance Society’s
Entry Field
Amount you
need to payYen
yourself
Determined
Amount ofYenAllowance

Bosch Health Insurance Society (Hig-RBHI), Healthcare Promotion Section, Person in Charge of Subsidy※Since an application document is equal to a security, the following sending method is recommended
for prevention of losing it and for clarification of the responsible party.
① Sending by general mail:(Bosch Health Insurance Society, 2-5-5 Yakyucho, Higashimatsuyama City, 355-0028)②

Please send it by registered mail or simple registered mail.

When “Internal Registered Mail Application” of Bosch internal mail can be used, please send it
upon writing the internal registered mail application with putting a � mark in the item of requesting “Thereceipt certificate”. (When “Internal Registered Mail Application” cannot be used, please send it making
use of the above-mentioned method ①.)

The information which you filled is collected for the purpose of our society to operate our service accurately and fairly according to Health
Insurance Act and other related notices of authorities. We don't use the personal information for other purposes than this purpose, nor provide it
to the third parties. In the meanwhile, there may an opportunity that we ask you for further details about the information which you filled and forthe additional evidencing documents, if necessary. For further question on the handling of the personal information or if you have a request for
information disclosure and so on, please contact Bosch Health Insurance Society General Affairs Section (Phone 0493-22-0890). ※ As for thehandling of personal information, please also see the home page, “Personal Information Protection Policy”. Revised on Apr, 2024