婦Gynecological Examination 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）

Insured
Person’s Name

Date： (M) 15

Kenpo Hanako
Contact Phone No.

XXXXXUnit NameXX －XX(D) 5 , (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 ExamName of Medical InstitutionUterusCancer
Exam(M) 4 (D) 15, (Y) 2024○○○ 病院

4,200Yen

BreastCancer
Exam(M) 4 (D) 30 , (Y) 2024△△△ 婦人科医院

7,500Yen【Conditions for Payment of Subsidy】
1.
2.
3.
4.
5.
6.

7.

8.

Total Amount

11,700Yen Yen

Object person： Female insured person of Bosch Health Insurance Society
Bosch Health Insurance
Object period： Every year from April 1 to March 31, next year
Society’s Entry Field
Number of applications： Once a year for respective exam item（※The different exam
（Please don’t fill in here.）
method is also regarded as one item.）
Amount ofSubsidy upper limits: For Uterus Cancer Exam ¥6,000, and for Breast Cancer Exam Exam Item
Allowance¥12,000
Uterus Cancer
YenApplication method: The subsidy bill + an original receipt are requested to be presented
Exam
to this Health Insurance Society. (The document cannot be returned.)
Breast Cancer
YenReceipt entry items： Name of the examinee, date of examination, name of medical
Examinstitution (seal), unit price per each examination, clear definition that the cost is for Determined
gynecological examination (uterus cancer exam / breast cancer exam)
TotalYenNote）We accept the receipt, even if it is of a receipt type slip, as long as above- Amount of
mentioned essential entry items are described and together with the receipt seal of the Allowance
medical 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 gynecological examination conducted at eachbusiness site
Limited to the examination conducted by a medical institution in Japan.

【Where to sendapplication】【Recommendedsending method】①Expense

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