Request for Payment of Medical Expenses for Insured Person or Dependent[for acupuncture and moxibustion]

Information on insured person

Insurance cardcode and number

CodeNumber●●XXXX

Furigana

Name of insuredperson〒123-4567
Address,
telephone number, etc.
XXXX Condominium, #456
(daytime phone number)

Date of birth of person
who received medical care

Hanako Kempo●● (Y) ●● (M) ●● (D)I had been receiving ongoing treatment for my back pain from my doctor, but with no relief from the pain.

Was the need for
medical care caused
by a third party(traffic accident, etc.)?

No/Yes※f the answer is "yes," a separate notification is required.

Date of first medical care(Y)●● (Y) ●● (M) ●● (D)1-2-3 XXXX-cho, XXXX Ward, Tokyo
E-mail address
XXXX＠XXXX.ne.jp

Phone number: 090-7891-2345

Cause of illness
or injury

Telephone number (ext.) 03-1234-5678(999）

Date of birth

Taro Kempo

Name of person who
received medical care

XXXX Co., Ltd., XXXX Branch

Name of affiliatedoffice/department(M)

No(D) From(Y)

(M)

(D)

to2. Rheumatism

5. Lower back pain

(Y)

(M)

3. Cervicobrachial syndrome

6. Cervical sprain (whiplash)/Yes※f 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. Moxibustionelectroacupuncture)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 fee

yen

Acupuncture

yenxtime(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

Ask the acupuncture / moxibustion
xtime(s) =practitioner to fill this yen
spaceout.
Up to 4 ｋm
yen xtime(s) =yenxtime(s) =Up to 4 ｋm

House call fee
House call fee

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

yenx

yen
yentime(s) =yen

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

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

(Y)

(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

AddressName
Name

Phone number

Record ofconsent

Remarks

Treatment
certificate

Summary

Name of consenting physicianAddress

Date of consent(Y)(M)Name of injury / illness

Period requiring
medical care(D)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)

Name1234

Bank Number

Date:567

Branch number
Bank

Name of financial
institution●●

Shinkin bank(credit treasury)

Savings accountType of accountChecking accountCentral branch●●Other()Account number

1234567

Name of accountholder(Katakana)Remarks

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.

branchTaro Kempo
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)