Insured

HealthInsurance

12Application Form(TherapeuticTo be filled out by the insured
Orthotic Devices)person (the applicant)Medical CareExpenses

FamilyPlease use double-sided printing to help simplify clerical duties.
Information regarding the insured person(Applicant)SymbolDate of Birth (MM. DD, YYYY)

NumberInsurance card
(Fill in from the rightside)

1 0 0 1
ボッシュ(Furigana)Name□ Showa

2 3 4 5 60 1 1 1 2 0□ Heisei✓

ケンポ

Bosch Kempo(〒355-TEL0493(AddressTelephone
number002822)

Saitama2-5-5 Yakyu-cho,Higashimatsuyama City0890)(Daytime contact)□ I delegate the authority to submit this application form to my employer. (Place a check mark in the box to delegate authority)

Designated transfer accountCreditUnion

BankName of financial
institution

Saitama Resona

Agricultural
Cooperative
Other

1

Account type

1. Ordinary 3. Special
4. Deposit at
2. Currentnotice(Account number

Shinkin
BankMainbranchHigashimatsuyama

Fishery
Cooperative)

7 6 5 4 3 2 1

BranchLocal office
Headoffice

BranchofficeFill in from the left side.

▼Katakana (Leave one square between your first and last name. Please write diacritic marks (“, °) as one character. )Account holder

ホ゛ ッシュ

Beneficiary agent field

Insured person(Applicant)Accountholder
category

ケ ンホ゜I delegate the authority to receive benefits based on this application form to
the following agent:

2. Agent

Date: Reiwa (Y)/ (M)/ (D)Address: Same as the address under “Information
regarding the insured person (Applicant)”Name(〒-)

TEL()

Address

AgentAgent(Accountholder)(Account holder)

1. Applicant1Relationshipbetween theDelegator andthe Agent(Furigana)Name“Applicant Entry Form” continues on page 2. 〉〉〉(R2.12)Name of the social insurance
and labor consultant serving
as the agent in submitting thisform

Reception date stamp

The personal information you provide here is collected by the Health Insurance Society in order to conduct business operations in a fair and equitable manner,and in accordance with the Health Insurance Act and related government notices. We do NOT use personal information or provide it to third parties for any
other purpose. In addition, we may ask you about the information you have provided, and, if necessary, we may request that you submit evidentiary documents
separately. For inquiries or requests for disclosure regarding the handling of your personal information, contact the Bosch Health Insurance Society General
Affairs Division at 0493-22-0890.
*For details on the handling of personal information, also refer to the “Privacy Policy” on our website.

Bosch Health Insurance Society
2-5-5 Yakyu-cho, Higashimatsuyama City, 355-0028 Internal mail: Hig RBHI

1/2

HealthInsurance

InsuredFamily

Name of theinsured person

Application details

1 Person receiving medicalcare

Medical CareExpenses

12Application Form(TherapeuticTo be filled out by the insured
person (the applicant)Orthotic Devices)

Kenpo BOSCH
1

1. The insured person

2. A dependent family member

1-(1) If a family member, thenNamethat person’sMM

3 Date of illness
onset or injury
occurring

Flat feet (both feet)

2 Name of injury or illness

4 Cause of injury and progress(in detail)

Date of birth

5 Medical institution wheretreatment was received

DD,YYYYDDYYMMDDYY□□ □□Name of physician etc.
providing treatment

LocationToMM

0 8 2 8 X X
FromName of physician etc.
providing treatment

Tokyoto Minatoku △ △67-8Name

FromMMDD

YY

Numberof days

0 9 1 6 X XTo

MMDD

3day(s)YY

Numberof daysday(s)MM

7 Date instructed to wear theorthotics etc.

16 20XXMM

Location○○Hospital

6-(1) If hospitalized during
the above period, thedates in hospitalYYYY

Heel pain from overloading due to obesity
Wearing the orthotic devices eliminates the pain.
Progress is good.
Name

6 Date(s) treatment wasreceived

09DD,DDMM

YY

8 Date orthotics
fitted0 8 2 8 X X

9 Expenses incurred fortreatment

25,000YenDD

YY

0 9 1 6 X X
Please enter the amounts basedon the attached original receipts.

10 Details of treatment

Scan, medical examination, fitting oforthotic devices for both feet

11 Reason for medical
expenses application

5

5. Having therapeutic orthotic devices made□✓ This application satisfies the conditions of (1) or (2). (Please check the box ☑. )(1) This application was prepared by the insured person (the applicant him/herself).
(2) The applicant him/herself has checked that the content of the application is correct.

Bosch Health Insurance Society

2/2Orthotic Device Fabrication
Confirmation Form (1)To be submitted only fortherapeutic orthotic devices

Response regarding fabrication of the orthotic devices applied for is necessary for the review and payment
of benefits.
Submission of this form is not required for fabrication of prescription glasses and compression garments.
Health insurance card
SymbolNumber1001

Name of the insured person

23456

Name of orthotic device madeName of person to whom devices were fitted

Kenpo BOSCH

Kenpo BOSCH

Date of fitting (date of purchase)

Orthotic devices
for both feet

09

MM

16DD,

20XX

YYYY

Please enter the appropriate number.
Q1: Is this the first time you have had an orthotic device made for this injury or illness?
1. First fabrication

1

2. Have had fabricated before; this is a new fabrication
3. Have had fabricated before; this involves repairs to an orthotic device still in use
Month and year of fabrication

Usage status

Fill in if you
selected 2 or 3

Month and year returned ordisposed of

1. Still using it now

AroundMMYYYY

2. Returned it to theorthotic supplier

AroundMMYYYY

3. Disposed of it

Q2. Do you have a disability passbook?
We would like to check whether you have a disability certificate to determine if you are eligible for orthotic device
expenses under the Act for the Comprehensive Support of Persons with Disabilities

2

1. I have one

Please attach a copy of your disability passbook

2. I do not have one

Q3: How did you fit the size of the orthotic device you had made?
1. Molding such as putting a plaster cast on the affected area and/or around it, or placing the footon plaster2. Taking detailed measurements of each part of the affected area and/or around it

1

3. Estimating the size with a tape measure to selecta ready-made product from sizes such as S/M/L(only sizing was taken)

Person who took
themeasurements

4. Took no action
5. OtherProvide details
here

Bosch Health Insurance Society

3

1. Physician 2. Nurse etc.
3. Orthotics supplierOrthotic Device Fabrication Confirmation Form (2)(for attaching photos)
How to take the photographs(1) Please affix photographs (plain paper is acceptable) in the box below. Please attach photographs
which cannot be affixed.
(2) Please take photos so that the entire orthotic device is visible.
(3) For orthotics that are inserted into shoes (such as insoles), please take them out of the shoes andphotograph them from above.
(4) If there are any sizes or logos printed on the orthotics, please photograph those areas as well.
(2) Please take photos so that the entire orthotic device is visible.
(3) For orthotics that are inserted into shoes (such as insoles), please take them out of the shoes and photograph them from above.

(4) If there are any sizes or logos printed on the orthotics, please photograph those areas as well.

Bosch Health Insurance Society