Information on insured person

Request for Payment of Medical Expenses for Insured Person or Dependent[Advance Payment on Behalf of Third Party]
Insurance cardcode and number

Number●●XXXX

Name of affiliated
XXXX Co., Ltd., XXXX Branch
office/department Telephone number (ext.) 03-1234-5678(999）

ケンポ タロウ

Furigana
NameAddress, telephone
number, etc. of applicant(daytime phone number)〒123-4567
XXXX Condominium, #456 1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

Employee ID number1234567

E-mail address

XXXX＠XXXX.ne.jpPerson undergoing medicaltreatment(circle the applicable person）

Insured person / Family member (dependent)

Name of person
undergoing medicaltreatment

Taro Kempo

Name of injury /illness

Influenza

Date of birth ofperson undergoing
medical treatment●● (Y) ●● (M) ●● (D)I had a high fever and underwent an emergency examination at a hospital while traveling.

Name of medicalinstitution
where examination wasconducted

Address of medical institution
where examination wasconducted

XXXX Hospital

Period during which
medical treatment
was conducted

From ● (Y) ● (M) ● (D)Cost of medical care

12,000If hospitalized during the period

to ● (Y) ● (M) ● (D)Reason for claim forpayment of medical care
costs
(Circle the applicablereason)● days listed on the left, the period ofthat hospitalization

yenContent of treatment

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

From

(Y)

(M)

(D)

to(Y)

(M)

(D)

days

Underwent medical treatment andreceived administration of drugs

Checking account()

Account number

Yes567
Central branch●●

Shinkin bank(credit treasury)
Other/※f the answer is "yes," a separate notification is required.

Branch number●●Savings accountNo

Date:Bank

Name of financial
institution

Type of account

X-X-X-cho, XXXX City,
Fukuoka Prefecture

1. I had just entered the company and had not yet received my insurance card
2. I was not carrying my insurance card, but I was forced to receive care at a medical institution due to sudden illness/injury
3. I used my previous insurance card
4. Other ()Was the need for
Was the need for
medical care caused
No / Yes
medical care caused
by a third party
by to work or on the(traffic accident,way to work?
※f the answer is "yes," a separate notification is required.
etc.)?
*If you wish to delegate receipt, please complete the authorization letter.

Information on transfer
destination●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo

Cause and progressof symptoms

Application details

Code1234567

Name of accountholder(Katakana)branchTaro Kempo[Documents for Attachment]
1. Certificate of medical remuneration (original) *If you are unable to attach the receipt, please obtain a physician’s certificate for the second sheet (itemized (medicaltreatment) receipt).
2. Receipt (original copy)

Remarks

Individual number (not required when entering the code and number from the insured person's card)

Date request received(stamp)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.
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 (bothsides)
・ 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)

Itemized (Medical Treatment) Receipt (Physician’s Certificate)*Please submit if you are unable to attach the Certificate of medical remuneration.

If you are unable to have the medical institution issue a Certificate of
medical remuneration, please ask the medical institution for a
Itemized (Medical Treatment) Receipt.
Month of medicaltreatment
Actual number of daysof medical treatment

Name of patient

Name of injury / illnesstime(s)pointsDate of hospitalization:time(s)pointsBed Treatment Basic hospitalization fees/additional feestime(s)pointsx

days

pointstime(s)pointsx

days

pointsFollow-up visittime(s)x

days

pointsAdditional fees foroutpatient care

Hospitaliza
pointstiontime(s)pointsx

days

pointstime(s)pointsx

days

pointstime(s)pointstime(s)points

Initial examination
Initial After-hours
examinatio
Days offn
Late-night

Follow-up
After-hours
visit
Days off
Late-nightSpecified hospital charges/ Other fees

Medicaladministrat
ion

pointsAt-homepoints

Dietaryhabits

Oral

Single dosepointsTaken only onceSingle dosepointsSingle dosepointstime(s)pointstime(s)pointsAdministra Topicaltion ofPrescription
drugs
Narcotic or
psychotropic agent

Basic dispensing fee
Subcutaneous

pointstime(s)pointstime(s)pointsProcedure Proceduretime(s)pointsSurgical Operation
anesthesia Anesthesia

time(s)pointstime(s)pointstime(s)points

Diagnostic
imagingtime(s)pointsOthertime(s)points

Other

Test

Test/pathology

yenxtime(s)Specialyenxtime(s)Dietyenxtime(s)Environment

yenxtime(s)yenxtime(s)Standardtime(s)xReduction / Exemption / Deferment / I / II / MarchSpecial

yenpointstime(s)Injection IntravenousStandard

Total

yen

I hereby certify receipt of the above (medical treatment）.

(Y)

(M)

(D)

Address of medical institution
Name of medical institution

Name of physician
Telephone number of medicalinstitution（）(20220401)