Request for Payment of Medical Expenses for Insured Person or Dependent

Information on insured person/Application details[for acupuncture and moxibustion]
CodeInsurance cardcode and number

NumberName of affiliatedoffice/department

Furigana

Name of insured
personAddress,
telephone number, etc.
(daytime phone number)Phone number

Date of birthof insured person

(Ext.

)

(Y)

(M)

(D)

(Y)

(M)

(D)

〒
Telephone number()

E-mail address
Date of birth ofperson
who received

Name of person
who received
medical care
Cause of illness
or injury
Was the need forNo / Yes
medical care caused
by a third party(traffic accident, etc.)? ※If the answer is "yes," a separate notification is required.
Date of first medical care
(Y)

(M)

No(D) From(Y)

(M)

(D)

to

2. Rheumatism

5. Lower back pain

(Y)

(M)

3. Cervicobrachial syndrome

6. Cervical sprain (whiplash)/Yes※If the answer is "yes," a separate notification is required.

Procedures period

1. Neuralgia

Name of injury /illness

Was the need for
medical care caused
by to work or on theway to work?

Actual numberof days

Claim classificationdays

New / Continuation(D)

4. Shoulder periarthritis (frozenshoulder)

Outcome)Continuation / Cured / Discontinued /Transfer to a different practitioner

7. Other (2. Acupuncture (combined use of
4. Moxibustion (combined use of electric heat
3. Moxibustion
electroacupuncture)therapy device)
5. Combination of acupuncture and6. Combination of acupuncture and moxibustion (combined use of electroacupuncture and electric heatmoxibustion
therapy device)

1. AcupunctureFirst time

Procedure column

Initial inspection feeyenAcupunctureyenxtime(s) =yen

Acupuncture (combined use of electroacupuncture)

yenxtime(s) =yenSecond and Moxibustion
subsequent
procedures Moxibustion (combined use of electric heat therapy device)yenxtime(s) =yenyenxtime(s) =yenCombination of acupuncture and moxibustion

yenxtime(s) =yenCombination of acupuncture and moxibustion (combined use ofelectroacupuncture and electric heat therapy device)yen

xtime(s) =yenHouse call fee

Up to 4 ｋm

yenxtime(s) =yenHouse call fee

Up to 4 ｋm

yenxtime(s) =yenyenxtime(s) =yen

Fees for issuing treatment report(Previously paid for date:(Month/Year))

Total amount of costs
Date of procedure
Visit to thepractice: 〇House call: ◎Monthyen

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Health center registration
classification

Record of Remarksconsent

Treatment
certificate

Procedures were carried out as shown above and related fees were received.

(Y)

Summary(M)1. Address of clinic

2. Address of professional practitioner making a house-call, etc.

(D)

Registration code number (registration number of reportedpractitioner)＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

ClinicClinic manager

Name of consenting physicianAddress
Name
Name

Phone numberAddress

Date of consent
(Y)

(M)

Name of injury / illness

Period requiring
medical care

(D)

Information on transfer
destination

Authorization Letter*If you wish to delegate receipt, please complete the authorization letter.
I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

Name

Representative(individual actually receiving benefits)

Name

Branch number

Bank Number

Name of financial
institution

Type of account

Savings accountChecking accountRemarks

Date:

Other()BankCentral branch

Shinkin bank(credit treasury)

branchAccount number

Name of accountholder(Katakana)

Individual number (not required when entering the code and number from the insured person's card)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.

Date request received(stamp)

One of the following: (1) Copy of individual number notification card, (2) Copy of certificate of residence listing individual number, (3) Copy of individual number card (both sides)
・ When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Accenture Health Insurance Society(20220401)