For insured women (employee, special retirement andextended coverage) of Fujitsu Health Insurance* Extended coverage limited to 30 and up (as of April 1, 2024)* Until the day before one's 75th birthday

Fujitsu Health Insurance Society 2024 Edition

Health Checkup Request Form (Gynecological checkup for insured persons)Please be sure to read this form.
You may receive one free health checkup during the fiscal year (from April 1 to March 31 of thefollowing year).
* Please note that a second examination of the same type will be at your own expense.
Flow from appointment and examination to receipt of results(1) Appointment

・Please apply by calling the health center of your choice from among the enclosed "List of Contracted HealthCenters."
・When making an appointment, be sure to tell them it is for a "Fujitsu Health Insurance Society Free Gynecological
Checkup."(2) Preparation

・The health center may send you a health checkup kit or other materials. If you have any questions, please ask thehealth center.
・Please prepare according to the health center's guidance.
・Please undergo a checkup on the day of your appointment. (In the unlikely event that you are unable to do so,
be sure to contact the health center.)・Please bring your Health Insurance Card and this Health Checkup Request Form.

(3) Examination(4) Receipt of result
notification

If additional tests other than those listed among the "Examination Items" on the reverse side are performed, youwill be required to bear the additional costs. There is no Fujitsu Health Insurance subsidy for such costs.
If you wish to undergo additional tests, please check with the health center regarding the amount you will berequired to pay and the payment method.
・You will receive a notice of the results of the health checkup from the health center at a later date.
・If the results indicate that you should undergo a full examination, be sure to do so at a medicalinstitution.
* Such further examinations and treatment are covered by insurance.

Form to Be Completed by the Examinee
Please complete the form in this frame and submit it to the health center on the day of the checkup.

Date of Checkup(YYYY/MM/DD)//□ Breast cancer screening + Cervical cancer screening

Breast cancer screening

Type of Checkup
Please check the appropriatebox (☑).

Mammography or breast ultrasound(echography)□ Mammography□ Breast ultrasound (echography))□ Breast cancer screening only

Cervical cancer screening(Breast cancer screening items:

Cervical cytology (physician-collected)

Health insurance card code

(Breast cancer screening items:□ Mammography□ Breast ultrasound (echography))□ Cervical cancer screening only
Health insurance card number<Requirements for Health Checkups>
(1)

(2)

Name

Must be an insured person (employee,
special retirement and extended coverage)of Fujitsu Health Insurance as of the date of
the examination.
Must be examined by the day before one's
75th birthday.

Date of Birth

Please enter the name on your health insurance card.
(YYYY/MM/DD)

Examinee//() years oldAddress and Contact Information(〒-)(Contact Phone No.

--)* Personal information collected using this form will not be used for any purpose other than to implement Fujitsu Health Insurance Society's health services. The
information will be properly managed in accordance with the Personal Information Protection Law.
* Fujitsu Health Insurance Society health checkup business is entrusted to Best Life Promotion, a wholly owned group company of Fujitsu.
Do not think you are fine merely because you underwent an annual health checkup; if you have noticed symptoms of concern, we recommend
seeking a medical consultation as soon as possible.

Fujitsu Health Insurance Society / Service provided by Best Life Promotion

[Gynecological checkup for insured persons]Examination Item

Details of Examination

Insured Person(Employee)Special Retirement(Insured Person)

All women

All women

Extended Coverage(Insured Person)

Age requirement
For 30 and up(As of April 1, 2024)

Breast examination
Palpation will be conducted upon the examinee's request. However, depending on the contract
with the health center, it may not be performed.

Breast cancer

Mammography or breast ultrasound (echography)
In principle, only one of these two examinations will be conducted. If you wish to have both
examinations, please contact the health center directly. It is possible to undergo both
examinations (although some health centers cannot accommodate this), but the cost of one of
the two examinations must be covered by the examinee. Please note that some health centers
may only provide mammography or breast ultrasound (echography).

Cervical cancer

Cervical cytology (physician-collected)