Request for Payment of Medical Expenses for Insured Person or Dependent[for massages]

Information on insured person/Application details

Insurance cardcode and number

CodeNumber●●XXXX〒123-4567
Address,telephone number, etc.
XXXX Condominium, #456
(daytime phone number)

1-2-3 XXXX-cho, XXXX Ward, Tokyo

Phone number: 090-7891-2345

E-mail address

Name of person
who received
medical care

Hanako Kempo

Date of birth of person
who received
medical care

Cause of illnessor injury

Sequela due to cerebral
hemorrhage

Was the need for medicalcare caused by a third party(traffic accident, etc.)?

XXXX＠XXXX.ne.jp●● (Y) ●● (M) ●● (D)No / Yes

I had been receiving ongoing treatment for my back pain from my doctor, but with no relief from the pain.
No/Yes※f the answer is "yes," a separate notification is required.

Date of first medical care(Y)●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo

Cause of illness
or injury
Was the need for
medical care causedby a third party(traffic accident,etc.)?

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

ケンポ タロウ

Furigana

Name of insured
personName of affiliatedoffice/department(M)

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

NoFrom

(Y)

(M)

(D)

to(Y)

(M)

Actual numberof days

Claim classificationdays

New / Continuation(D)

OutcomeProcedure column

Name of injury/illness or
symptomContinuation / Cured / Discontinued /Transfer to a different practitioner

Massage

Trunkyenxtime(s) =yen

Right upperlimb

yenxtime(s) =yen

Left upper limb

yenxtime(s) =yen

Right lower
limb

yenxtime(s) =yenyenxtime(s) =yenyenxtime(s) =yenyenLeft lower limb

Correction of structural deformities

Hot fomentation

yenxtime(s) =Hot fomentation / electro therapy device

yenxtime(s) =yentime(s)yen

Ask the masseuseout.
yen xto fill this space=

Up to 4 ｋm

House call fee
House call fee

More than 4 ｋm

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

yen

Total
Date of procedure
Visit to thepractice: 〇House call: ◎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
certificate

Procedures were carried out as shown above and related fees were received.

Record ofRemarks
consent

SummaryyenMonth(Y)Yes※f the answer is "yes," a separate notification is required.

Procedures period(D)/(M)

1. Address of clinic

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

(D)

Registration code number (registration number of reportedpractitioner)＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

ClinicClinic manager

Name of consenting physician

AddressName
Name

Phone numberAddress

Date of consent

Name of injury / illness

Period requiring medicalcare

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)

Name

Representative(individual actually receiving benefits)

Name1234

Bank Number

567

Branch numberBankName of financialinstitution

Type of account

Date:

●●
Savings accountChecking accountCentral branch●●

Shinkin bank(credit treasury)
Other()

Account number

1234567

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.

branchTaro Kempo
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)