Revised April 2021

For expectant mothers

Persons who satisfy all of the following 3 prescribed●Compensation eligibility conditions are eligible for compensation:
Children born between
2015 - 2021

Registration Certificate for The Japan ObstetricCompensation System for Cerebral Palsy* If you have already registered this birth at another hospital, please provide your expectant or nursing mother management
registration number. When registering, the expectant or nursing mother management number will take priority.

*Registered expectant or nursing
mother management number

Gestational week at the 32nd1week or later and a birth weightof 1,400g or more, or
28th week or later, and fulfilling

Gestational weekat the 28th weekor later

specified requirements.

2

Cerebral palsy corresponding to the 1st or 2nd degree of physicaldisability based on the Japanese system

3

Cerebral palsy which is not caused by congenital or neonatal reasons[About expectant and nursing mothers enrolled in the Japan Obstetric Compensation System]

In addition to promptly compensating for the economic burden that affects families with children who have severe
cerebral palsy, this system seeks to avoid conflict and reach an early resolution, and strives to improve the quality ofobstetric care by analyzing the cause and providing contributory knowledge to prevent recurrence of similar cases.

Section to be filled in by theexpectant or nursing mother
Name

Furigana(Syllabic characters)●Compensation details

Name

A lump-sum payment for preparation and periodic installment
payments for compensation for a total of 30 million yen will be provided.

●Compensation application period

Please fill in the sections with the thick borders. This registration
certificate uses carbon paper to make a copy. Therefore, pleasefill out with a ballpoint pen, pressing it down on the paper firmly.

キコウハナコ

Family nameFirst name

KIKOU

BirthdayFrom the child's first birthday until his/her fifth birthday.

Phone number*However, if it is an extreme case of serious disability and diagnosed as such,application for compensation is eligible for children after 6 months of age.

Date of registration

Date

YYYY/MM/DD

Date of registration

1090 − 2222/

23− 222X

Date

YYYY/MM/DD

2021 /

12 /1Date

YYYY/MM/DD

2022 /7/1

Due date

Expecteddue date*If you are filling this out after delivery, please enter the actual delivery date. If you are transferring fromanother hospital which has issued a registration certificate, please enter your expected due date.

Number of expected births

Number ofexpected births* If you are unable to access the Internet to view the Compensation Terms ofAgreement, please contact this hospital or the call center specified by this system.
* Any communication charges required to view or download from this site shallbe borne by the user.

1990 /* Please provide your cell phone number, if possible.

(Certificate Issuance Date)

http://www.sanka-hp.jcqhc.or.jp/documents/agreement/index.html

HANAKOBirthday

Phone number●To view the Compensation Terms of Agreement, please see thefollowing website or use the QR code.

020000001X

Expectant or nursing mothermanagement numberChildren born after
2022

1Persons*Please enter the number of expected
number of births.
For example, in case of twins, please enter 2.

About expectant and nursing mothers enrolled in the Japan Obstetric Compensation System
All expectant mothers who give birth at a childbirth facility (hospital, clinic or childbirth home) which is enrolled in the Japan ObstetricCompensation System are eligible for this compensation system (registration required). In cases of childbirth under the management of thishospital, this registration certificate verifies eligibility for this system.

● Please fill this out and promptly submit it to this hospital . This certificate will be provided as a copy.
● Please keep this certificate in a safe place, such as inserting it in the Mother and Child Health Handbook ,for 5 years after birth .
● In cases of transfer to another childbirth facility from this hospital, please be sure to present thiscertificate to the new childbirth facility.

Name of Corporation or Childbirth FacilityChildbirth facility management numberInquiries

Japan Obstetric Compensation System Special Call Center

0120 330 637

Hours:

9:00 a.m. - 5:00 p.m. (Closed Saturday and Sunday, End of Year and New Year Holidays)

Japan Obstetric Compensation System website

http://www.sanka-hp.jcqhc.or.jp/

sanka jcqhc

searchThis logo represents“The Japan ObstetricCompensation Systemfor Cerebral Palsy”

A103(15)21.04(revised)