Information on insured person/Application details

Request for Payment of Medical Expenses for Insured Person or Dependent[for massages]
CodeInsurance cardcode and number

NumberFurigana

Name of insured
personAddress,
telephone number, etc.
(daytime phone number)

Name of person
who received
medical care
Cause of illness
or injury
Was the need for
medical care caused
by a third party(traffic accident,

Phone number(Ext.

Date of birthof insured person

Telephone number

()

(Y)

(M)

(D)

(Y)

(M)

(D)

E-mail address
Date of birth of person
who received
medical care

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

(M)

Was the need for
medical care caused
by to work or on theway to work?

No

Procedures period

(D)

From

(Y)

(M)

(D)

to(Y)

(M)

Claim classificationdays

New / Continuation(D)

OutcomeProcedure column

Continuation / Cured / Discontinued /Transfer to a different practitioner
Trunkyenxtime(s) =yenyenxtime(s) =yenLeft upper limb

yenxtime(s) =yen

Right lowerlimb

yenxtime(s) =yenLeft lower limb

yenxtime(s) =yenCorrection of structural deformities

yenxtime(s) =yen

Hot fomentation

yenxtime(s) =yen

Hot fomentation / electro therapy device

Massageyenxtime(s) =yen

Up to 4 ｋm

yenxtime(s) =yenHouse call fee

More than 4 ｋm

yenxtime(s) =yenFees for issuingtreatment report(Previously paid for
date: (Month/Year))yenxtime(s) =

yen

Total

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

Treatment
certificateProcedures were carried out as shown above and related fees were received.

(M)

1. Address of clinic

2. Address of professional practitioner making a house-call, etc.

(D)

Registration code number (registration number of reportedpractitioner)

Clinic＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Clinic manager

Record ofRemarks
consent

SummaryyenMonth(Y)Yes

Actual numberof days

Right upperlimb

Date of procedure
Visit to thepractice: 〇House call: ◎/※If the answer is "yes," a separate notification is required.

Name of injury/illness orsymptom

House call fee)〒

Date of first medical care(Y)

Name of affiliatedoffice/department

Name of consenting physicianAddress
Name
Name

Phone number

Address

Date of consent

Name of injury / illness

Period requiring
medical care

Date:

Information on transfer
destination

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)

NameRepresentative(individual actually receiving benefits)

Name

Branch number

Bank Number

Name of financial
institution

Type of account

Date:

Savings accountChecking account

Other()Bank

Central branch

Shinkin bank(credit treasury)

branchAccount number

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.

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)