�����������������������������������Date:(YYYY/MM/DD)

Application form for medical certificates, etc.
Patient ID
Patient
nameAddress□Inpatient��□Outpatient〒�����−Certificate validity period etc.

Dept

YM

D 〜Y

M

DDept

YM

D 〜Y

M

DDept

YM

D 〜Y

M

D

□Inpatient□Outpatient

Type ofcertificate.
etc.

□Hospital-prescribed (�� copy(ies))��������3,300 yen/copy□Life insurance (��� copy(ies))��������7,700 yen/copy□Birth notification (�� copy(ies))��� ���3,300 yen/copy□Death certificate (��� copy(ies))����� �4,400 yen/copy□Disability pension certificate( copy(ies))����� �7,700 yen/copy□Death certificate (for insurancecompany)� (� copy(ies))�������11,000 yen/copy□Injury and disease allowance(�����copy(ies))
100 points (insurance applicable)□Visiting nursing instructions(��� copy(ies))
300 points (insurance applicable)□Medical certificate in foreign language(��� copy(ies))
11,000 yen/copy□Automobile liability insurance(��� copy(ies))������� 7,700 yen/copy□Automobile liability insurance
statement (��� copy(ies))������� 5,500 yen/copy□Other (�� copy(ies))��������7,700 yen/copy

�■�With regard to the medical certificates below those applying for the first time must go to thePatient Consultation counter.
□Disability certificate (�� copy(ies))��������7,700 yen/copy□Designated intractable disease(�� copy(ies))����� �3,300 yen/copy□Pediatric chronic diseases(�� copy(ies))
250 points (insurance applicable)

Total�����copy(ies)I have checked the details of the application and agree to pay the expenses incurred.

Applicantname□Patient��□Other （Name：�������������Relationship：��������）��Note: a letter of proxy is required in the case of requests made by third parties.

Recipientname□Patient��□Other（����������������）Contact phone number�□�Home/mobile [�������������������]���� �□�Workplace, etc.�[���������������������]�����
□Notification���� �□�Hospital Ward (in hospital):necessary
East Ward
Floor / West Ward
Floor / Advanced Medical Care Center

Notification

Floor

Can a message be left on your phone?��Yes ・ No

□Notification unnecessary�・In the case of multiple applications□Contact me when they are all ready□Contact me as eachdocument becomes readyNote 1�Please provide a telephone number as your contact number where it will be definitely possible to contact you.
Note 2�Once complete the documents will be checked and then handed over to you on the next weekday. Your kindunderstanding is appreciated.

Please also complete the reverse side.

□At hospital counter������□By post (commission fee: 1,570yen)

How to□Hospital Ward*deliverdocuments

Eas�Ward

Floor / West Ward

Floor / Advanced Medical Care Center

Floor*Some time is required for the creation of the documents. Inpatients who wish to have them before discharge should ask directly at their hospital ward.

Remarks●Those applying for renewal of Specific Pediatric Chronic Disease certificates (medical opinion) must complete the following details.

・Prefecture of birth: [�]� ・Mother’s birth date: [����Y ��M� �D ]・Weight at birth: [���������g ]・Weeks of pregnancy：[���������Weeks]
・Registered address at time of birth：[����������Prefecture: ������� ����City/Town/village�]・State of study/employment: [������������������������������������������������������]・What, if any, other medical certificates do you possess?：[������������������������������������������� ]Note: Those who do not have a medical opinion form when applying to renew Specific Pediatric Chronic
Disease certificates are requested to write the name of the disease here:
Disease name: [���������������������������](This columnfor hospital use)

□System registration complete□System response N/A