Information on insured person

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

NumberName of affiliatedoffice/department

Phone number

(Ext.

)

Furigana
Name
Address, telephone
number, etc. of applicant(daytime phone number)

Date of birth

(Y)

(M)

(D)

〒
Phone number

Employee ID
number(Ext.

)

E-mail address

Person undergoing medicaltreatment(circle the applicable person）

Insured person / Family member (dependent)

Name of person
undergoing medicaltreatment
Date of birth of
person undergoing
medical treatment

Name of injury /illness

(Y)

(M)

(D)

Application details

Cause and progressof symptoms
Name of medicalinstitution
where examination wasconducted

Address of medical institution
where examination wasconducted

Period during which
medical treatment
was conducted

From

(Y)

(M)

(D)

If hospitalized during the period

to(Y)

(M)

that hospitalization(D)

Cost of medical careyen

Reason for claim forpayment of medical care
costs
(Circle the applicablereason)Authorization Letter

(Y)

(M)

(D)

to(Y)

(M)

(D)

days

Content of treatment

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

Fromdays listed on the left, the period ofI 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

No/

Yes

※If the answer is "yes," a separate notification is required.

Date:

Branch number

Bank Number

Bank

Name of financial
institution

Central branch

Shinkin bank(credit treasury)

Savings accountType of accountChecking account

Other()

Account numberbranch
Name of accountholder(Katakana)[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
(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)

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

Hospitaliz
pointsationtime(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

Specified hospital charges/ Other fees
Late-night
Medicaladministrationpoints

At-homepoints

Dietaryhabits

Oral

Single dosepointsTaken only onceSingle dosepointsAdministra Topicaltion ofPrescription
drugs
Narcotic or
psychotropic agent

Single dose

Subcutaneous

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

time(s)pointstime(s)pointstime(s)pointsDiagnostic
imagingtime(s)pointsOthertime(s)points

Other

Test

Test/pathology

xtime(s)Specialyenx

time(s)Dietyenxtime(s)Environment

yenx

time(s)yenxtime(s)Standard
Specialyenpointstime(s)Injection Intravenous

yentime(s)xpoints Reduction / Exemption / Deferment / I / II / Marchtime(s)Basic dispensing fee

Standard

Totalyen

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)