Request for Payment of Medical Expenses for Insured Person or Dependent
Information on insured person[for therapeutic devices, therapeutic eye glasses, etc.]
CodeInsurance cardcode and number

Name ofaffiliatedoffice/department

NumberFurigana
Name
Address, telephone
number, etc. ofapplicant(daytime phonenumber))
(Y)

(M)

(D)

(Y)

(M)

(D)

〒
Phone number

(Ext.

)

E-mail address

Insured person / Family member (dependent)

Name of injury /illness

Name of person
undergoing
medicalDate of birth ofperson
undergoing

Cause andprogress ofsymptoms

Application details(Ext.

Date of birth

Employee ID
number
Person undergoing
medical treatment(circle the applicableperson）

Phone number

Date of injury
or onset of illness

Name of medical
institution where
examination wasconducted

(Y)

(M)

(D)

Address of medical
institution where
examination wasconducted

From

Period during which
medical treatment wasconducted

(Y)

(M)

(D)
days

to(Y)

(M)

(D)

Cost oftherapeutic
devices, etc.

yenContent oftreatment

1. Wearing of therapeutic devices, etc.
2. Creation of therapeutic eye glasses, etc.
3. Other (If hospitalized during theperiod listed on the left,
the period of that
hospitalization

From(Y)

(M)

(D)

to(Y)

(M)

(D)

days

Date of attaching
therapeuticdevices, etc.

(Y)

(M)

(D)

Information on transfer
destination

Authorization Letter)
Was the need for
Was the need for
medical care
medical care
No / Yes
No / Yes
caused by a third
caused by toparty (trafficwork or on theaccident, etc.)? ※If the answer is "yes," a separate notification is required. way to work? ※If the answer is "yes," a separate notification is required.
*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 receivingbenefits)

Name

Date:

Branch number

Bank Number

Name of financial
institution

Savings accountType of accountChecking accountBank

Central branch

Shinkin bank(credit treasury)

branchOther()

Account number

Name ofaccount holder(Katakana)■ 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)