Health
Insurance

Insured

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)□ Showa□ Heisei(Furigana)Name(〒-TEL()

Address
Telephonenumber)(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 accountCreditUnionBank

Name of financial
institution

Agricultural
Cooperative
Other

1. Ordinary 3. Special
4. Deposit at
2. Current
noticeAccount type(ShinkinBankMain
branchFishery
Cooperative

BranchLocal office
Headoffice)Account number

BranchofficeFill in from the left side.

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

Account holder

Beneficiary agent field

Insured person(Applicant)I delegate the authority to receive benefits based on this application form tothe following agent:

2. Agent

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

TEL()

Address

Agent
Agent
(Accountholder)(Account holder)

1. Applicant

Relationshipbetween 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 GeneralAffairs 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

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HealthInsurance

InsuredFamily

Medical CareExpenses

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

Name of theinsured person

Application details

1 Person receiving medicalcare

1. The insured person

2. A dependent family member

1-(1) If a family member, thenName
that person’s

Date of birth
3 Date of illness
onset or injuryoccurring

2 Name of injury or illness

MMDD,

YYYY

MMDD,

YYYY

4 Cause of injury and progress(in detail)5 Medical institution wheretreatment was received

FromMM

DD

Name

Location

Name of physician etc.
providing treatment

Name

Location

Name of physician etc.
providing treatment

YYToMMDD

YY

6 Date(s) treatment wasreceived

Numberof daysday(s)6-(1) If hospitalized during
the above period, thedates in hospital

FromMMDD

YYTo

MMDD

YY

Numberof days
day(s)

MMDD

MM

YY

7 Date instructed to wear theorthotics etc.

DDYY

8 Date orthotics
fitted9 Expenses incurred fortreatment

Yen

10 Details of treatment

11 Reason for medicalexpenses 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 Society2/2

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 paymentof benefits.
Submission of this form is not required for fabrication of prescription glasses and compression garments.
Health insurance card
SymbolNumberName of the insured person

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

Date of fitting (date of purchase)
MMDD,

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
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 or
disposed 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

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
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

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