Request for Payment of Medical Expenses for Insured Person or Dependent

Application details

Information on insured person[for therapeutic devices, therapeutic eye glasses, etc.]
Insurance cardcode and number

CodeNumber●●XXXX

Name of affiliatedoffice/department

ケンポ タロウ

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

1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

Employee ID
number1234567

E-mail address

XXXX＠XXXX.ne.jp

Person undergoing medicaltreatment(circle the applicable person）

Insured person / Family member (dependent)

Name of person
undergoing medicaltreatment

Hanako Kempo

Name of injury /illness

Fracture of upper right humerus

Date of birth ofperson undergoing
medical treatment

Cause and progressof symptoms

Fell down stairs at home and fractured humerus

Name of medical
institution where
examination wasconducted

From ● (Y) ● (M) ● (D)Period during which
medical treatment wasconducted●to ● (Y) ● (M) ● (D)28,000daysyen

Was the need for
medical care caused
No / Yesby a third party(traffic accident,※If the answer is "yes," a separate notification is required.
etc.)?
*If you wish to delegate receipt, please complete the authorization letter.

Representative(individual actually receiving benefits)

Name

1234

Bank Number

From

(Y)

(M)

(D)

to(Y)

(M)

(D)

days

● (Y) ● (M) ● (D))
Was the need for
medical care caused
by to work or on theway to work?

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

Date:

567

Branch numberBank

Name of financialinstitution●●Checking accountCentral branch●●Shinkin bank(credit treasury)

Savings accountType of account

Other()●● (Y) ●● (M) ●● (D)X-X-X-cho, XXXX City,Fukuoka Prefecture

Date of attaching
therapeutic devices,etc.

I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Name

Date of injury
or onset of illness

If hospitalized during the period
listed on the left, the period ofthat hospitalization

1. Wearing of therapeutic devices, etc.
2. Creation of therapeutic eye glasses, etc.
3. Other (Insured person(applicant)●● (Y) ●● (M) ●● (D)Address of medical
institution where
examination was conducted

XXXX HospitalContent oftreatment

Authorization Letter●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo

Cost of therapeutic
devices, etc.

Information on transfer
destination

XXXX Co., Ltd., XXXX Branch
Telephone number (ext.) 03-1234-5678(999）

Account number1234567

Name of accountholder(Katakana)branchTaro Kempo■ Documents for Attachment[For Therapeutic Devices][For Therapeutic Eye Glasses, etc.]

1. Physician's certificate, instructions, or written diagnosis (original copy)

1. Physician’s written instructions for creation of therapeutic eye glasses, etc.

2. Receipt (original copy)

2. Patient examination/test results

3. Written document confirming wearing of the device (photograph of the created Shoe-shaped orthotic device)

3. 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)