Example of Completed Application
Managing director Office manager

Person in charge

Health Insurance Application for Eligibility Certificate for Ceiling-Amount/Reduction of the Standard Amount of Patient Liability

Insurance card code andnumberName
Name of insured
personOffice100

CodeEmp.
No.

○○○○○

NumberPlease enter the name and dateof birth for the person
applying for reduction.

○○○○○

Taro Kempo(Y)

Date of birth(M)(D)
Please enter the relationship tothe applicant as viewed fromthe insured person.

xxxxx Co., Ltd.

Office nameAddressName
Person applyingfor reduction Date of birth
Address of insured person(person applying forreduction)

Postalcode

Hanako Kempo

Relationship

WifeMay 2, 1975

GenderMale / Female

130 –0013

Telephonenumber–

○○

○○○○

–

○○○○

X-X-X Kinshi, Sumida Ward, Tokyo
Qualified / Not qualified

Long-term hospitalization

The following section can only be completed by applicants who are qualified as undergoing long-term hospitalization.

(1)

(2)

(3)

Hospitalization period (number ofdays) during the 1 year prior to theapplication date
Authorized insurance medical
institution, etc., where hospitalized
Hospitalization period (number ofdays) during the 1 year prior to theapplication date
Authorized insurance medical
institution, etc., where hospitalized
Hospitalization period (number ofdays) during the 1 year prior to theapplication date
Authorized insurance medical
institution, etc., where hospitalized

Total number of days
hospitalized(91 days)

Date: From October 25, XXXX

51 days

to December 14, XXXX
Name ofinstitution

Address

XXXX Association XXXX Hospital
1-1 XXXX-cho, Aoi Ward, Shizuoka City

Date: From January 10, XXXX

40 days

to February 18, XXXX
Name ofinstitutionXXXX Association XXXX Hospital

Address

1-1 XXXX-cho, Aoi Ward, Shizuoka City

For the period fromto(Year)(Year)(Month)(Month)

(Day)

days

(Day)

Please enter the address of theapplicant.

Name ofinstitution

Please circle one of the options
regarding qualification for
long-term hospitalization.
A person is qualified for longterm hospitalization if thenumber of days hospitalized
during the 12-month periodprior to application (limited tothe number of days
hospitalized as an applicant forreduction) exceeds 90 days.

When qualifying as longterm hospitalization, please
enter the hospitalization
period.
Name and address ofauthorized insurance
medical institution, etc.,
where hospitalizedAddress□Address of the insured person
person□Other [Home / Hospital]□Address of the eligible✔

Desired destination for sending
the Eligibility Certificate for*Please enter any necessary names (addressee/care of), room numbers, etc.
Ceiling-Amount/Reduction of
the Standard Amount of Patient 〒Liability
Section for listing individual number of insured person (not required
when listing the code and number of the insured person’s health insurance card)

I hereby attach the related documents and request the issuance of an “Eligibility Certificate for CeilingAmount/Reduction of the Standard Amount of Patient Liability” as stated above.
To the Executive Head of the Accenture Health Insurance Society
Issuance date:(*) Section
This certifies that the insured person is not subject tofor
the municipal tax in the ____ fiscal year.
certification
by municipal
head

Reiwa (Y)(M)
Name of municipal
headPlease use this section forlisting proof from themunicipal head in regards
to taxation.
It is not necessary tocomplete this section whenattaching a tax exemptioncertificate.

(D)(Seal)*A tax exemption certificate for municipal tax can be attached instead of a certificate from the municipal head.

[Documents for Attachment]
1. Persons who are exempt from municipal tax must attach a tax exemption certificate from the municipality.
The attachment is not necessary if certification has been received in the certification section on the front of the application.
2. For persons who are not required to be protected under the Public Assistance Act due to the reduction of the standard amount, please attach the“Notice of Rejection of Protection Application” that lists “Eligibility Certificate for Ceiling-Amount/Reduction of the Standard Amount of Patient
Liability (C),” or the “Notice of Decision to Rescind Protection,” or a copy of these documents with proof of the original from the employer, welfareofficer, or welfare office manager.
3. Persons who apply as qualifying for long-term hospitalization must attach a receipt for the standard amount.
(If there is a period not associated with the standard amount during the hospitalization period, please attach documents certified by the authorized
insurance medical institution, etc., for the hospitalization period).

[Matters to Note]
1. Please use this application form when the insured person is exempt from municipal tax for the fiscal year to which the month of medical treatment
belongs.
2. If you are injured or become ill during work or commuting, you cannot apply for a reduction certificate because you cannot use health insurance.
3. Separate notification is required in the case of injury or illness caused by a third party such as a traffic accident. Please contact the health insurance
society.

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