Health insurance eligibility and application-related forms

Some application forms can be submitted using your My Number.
If you wish to use your individual number (My Number) instead of symbols/numbers to submit an application, you will be required to submit additional documents. Please inquire with the health insurance society for further details.

form	EXCEL	PDF	Example
Notification of Health Insurance Dependent (Change) (for dependent certification)
Notification of Health Insurance Dependent (Change) (for removal from the list of dependents)
Dependent Status Questionnaire (A) (for Spouse/ Children)
Dependent Status Questionnaire (B) (for Family Members Other Than Spouse/Children)
Application Form for Issue of Eligibility Verification Certificate
Notification of Lost or Damaged Eligibility Verification Certificate/Health Insurance Card
Request for Health Insurance Certificate
Notification of Individual Number (My Number) Change/Correction			―
Application for Eligibility for Coverage as a Voluntarily and Continuously Insured Person (and Dependent Notice)
Dependent Status Questionnaire (A) (for Voluntarily Continuously Insured’s Spouse/Children)
Notification of Name Change (Correction) of Insured Person (only for Voluntarily Continuously Insured Person)			―
Notice of Disqualification as a Voluntarily Continuously Insured Person			―
Health Insurance Voluntary and Continuous Insurance Premium Refund Application and Invoice			―
Address Change Notice * Attach the document that shows your new address such as driver's license, certificate of residence, etc. (copies are acceptable). * Full-time employees are not required to give a notification to the Health Insurance Society directly. Change the address information in the personnel system.			―

Benefit and claims-related forms

Please inquire with the health insurance society in advance if any of the following applies:

• If you wish to use your individual number (My Number) instead of symbols/numbers to submit an application. (You will be required to submit additional documents)
• If you wish to use the account registration system for receipt of public funds to submit an application.

form	EXCEL	PDF	Example
Request for issuance of Maximum Co-payment Certificate for Health Insurance （Apply before hospitalization. After paid at the counter, the application is unnecessary)
Application Form for Medical Care Expenses (for Insured / Dependent )(Treatment orthosis, glasses)
Application Form for Medical Care Expenses (for Insured / Dependent )(Do not present health insurance card)
Application Form for Medical Care Expenses (for Insured / Dependent)(Acupuncture, Moxibustion, Anma massage, Massage)
Application for Benefits for Overseas Medical Costs (for Insured/ Dependent)
Application for Payment of Difference in Childbirth and Childcare Lump-Sum Grant and Additional Benefits (Partial Reimbursement Application)
Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf)
Application for Childbirth and Childcare Lump-Sum Grant (Additional Benefit)
Claim for Maternity Allowance/ Additional Sum
Injury and Sickness Allowance (Additional Sum) Application/ Extension Request
Claim for Funeral Expenses/ Additional Sum (for Insured/ Dependent)（If the insured person has died）
Claim for Funeral Expenses/ Additional Sum (for Insured/ Dependent) （If a family member has died）

Health activities-related forms

form	EXCEL	PDF	Example
Request for Assistance with Family/Resident Examination Costs
Application form for sending childcare book			―