胃Stomach cancer screening Subsidy Bill

Messrs. Bosch Health Insurance Society,※Voluntarily continued insured persons are requested to apply using“Health Service / Expense Application”.

【Applicant (Insured Person)】Insurance
CardSymbolNo.

9999
99999

Site Name（CompanyName）

Date： (M) 5

Kenpo Taro

Insured
Person’s Name

Contact Phone No.

XXXXXUnit NameXX －XX(D) 15 , (Y) 2024

／XX-XXXX-XXXX

XXXX【Exam Status】

Once a year for each item（※The different exam method is also regarded as one item.）Exam Item

Date of Exam

Gastricendoscopy(M) 4 (D) 15, (Y) 2024○○○ 病院

15,000Yen

stomachx-ray(M) 4 (D) 30 , (Y) 2024△△△ 医院

Yen

Name of Medical Institution【Conditions for Payment of Subsidy】
1.
2.
3.
4.
5.
6.

7.

8.

application】【Recommended
sending method】①

Total Amount

Object person：Insured person of Bosch Health Insurance Society (35 years or older)
Object period： Every year from April 1 to March 31, next year
Number of applications： Up to once a year （Gastric endoscopy or stomach x-ray）
Subsidy upper limits: Gastric endoscopy ¥18,000, and stomach x-ray ¥14,000
Application method: The subsidy bill + an original receipt are requested to be presented
to this Health Insurance Society. (The document cannot be returned.)
Receipt entry items： Name of the examinee, date of examination, name of medical
institution (seal), unit price per each examination, clear definition that the cost is forstomach cancer screening ( Gastric endoscopy or stomach x-ray)Note）We accept the receipt, even if it is of a receipt type slip, as long as abovementioned essential entry items are described and together with the receipt seal of themedical institution. (All the descriptions shall be filled at the medical institution.)
Cases where you are not eligible for payment:① When the health insurance card was used
② When you received a conducted stomach cancer screening at eachbusiness site
Limited to the examination conducted by a medical institution in Japan.

【Where to send

Expense15,000Yen Yen

Bosch Health InsuranceSociety’s Entry Field（Please don’t fill in here.）Amount of
Exam Item
Allowance
Determined
Total
Yen
Amount ofAllowance

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 isrecommended for prevention of losing it and for clarification of the responsible party.

Sending by general mail: Please send it by registered mail or simple registered mail.(Bosch Health Insurance Society,2-5-5 Yakyucho, Higashimatsuyama City, 355-0028)② 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 noticesof 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 weask you for further details about the information which you filled and for the 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 the handling of personal information, please also see the home page, “Personal Information Protection Policy”. Revised on Apr, 2024