Application forms
Insurance card and application-related forms
| Conditions | Required documents | Excel | Deadline |
|---|---|---|---|
| Adding or Removing a dependent | Notification of Health Insurance Dependent (Change)/Survey Form |  |
Within 5 days |
| Dependency notice | |
Within 5 days | |
| Dependent Residence Status Change Application | |
Immediately | |
| If you lose your health insurance card or it is damaged | Application Form for Reissue of Health Insurance Card (Card loss/Damage) | |
Immediately |
| Change of name or address of Insured Person (dependent) | Notification of Name Change of Insured Person (dependent) | |
Immediately |
| If you wish to remain a member of the Health Insurance Society | Application Form for Certification as Voluntarily and Continuously Insured Person | |
Within 20 days after the date of loss of eligibility |
| Change of name or address of a Voluntarily and Continuously Insured Person | Notification of Name or Adress Change of Voluntarily and Continuously Insured Persons | |
Within 5 days |
| If you lose your eligibility as a Voluntarily and Continuously Insured Person | Notice of Loss of Eligibility as a Voluntarily and Continuously Insured Person | |
Immediately |
| When you are exempt from the long-term care insurance program | Notification of Long-term Care Insurance (Qualification/Disqualification) | |
Immediately |
| Submit to: |
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Benefit and claims-related forms
| Conditions | Required documents | Excel | Deadline |
|---|---|---|---|
| Childbirth
If you cannot receive pay during time off from work for childbirth |
Application for Partial Reimbursement for Childcare Lump-Sum Grantt/Additional Sum (using the system of direct payment) | No submission required |
|
| Claim for Childbirth and Childcare Lump-sum Grant(not using the system of direct payment) | |
Immediately | |
| Claim for Childbirth and Childcare Lump-sum Grant(not using the system of direct payment, for Childbirth overseas ) | |
Immediately | |
| Agreement of Authorization(for Childbirth overseas ) | |
Immediately | |
| Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf) | |
Immediately | |
| Notice of Withdrawal of Receipt on Your Behalf of Childbirth and Childcare Lump-sum Grant | |
Immediately | |
| Notice of Change in Recipient on Your Behalf of Childbirth and Childcare Lump-sum Grant | |
Immediately | |
| Claim for Maternity Allowance | |
Immediately | |
| If you take time off from work due to sickness | Claim for Injury and Sickness Allowance | |
Immediately, each month |
| Death | Claim for Funeral Expenses | |
Immediately |
| If you were compelled to visit a medical care institution due to sudden sickness or injury arising when you did not have your health insurance card, if you paid medical care costs yourself because your health insurance card was still being processed, or if you had prosthetic equipment prepared as necessary for medical care |
Application Form for Medical Care Expenses It is necessary to attach pictures of orthopedic footwear. |
|
Immediately Please attach pictures for orthopedic footwear. |
| If you become sick or are injured overseas | Application Form for Medical Care Expenses | |
Immediately |
| Agreement of Authorization | |
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| Attending Physician’s Statement (for General Practice): Form A | |
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| Attending Physician’s Statement (for Dental Practice): Form B | |
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| Itemized Receipt (for General Practice): Form C | |
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| If you underwent acupuncture, moxibustion, massage, or similar treatment | If you underwent acupuncture, moxibustion, massage, or similar treatment | |
Immediately |
| If you cannot walk to or between hospitals | Application Form for Transportation Expenses | Please contact Health Insurance Society. | Immediately |
| If you have been in a traffic accident etc. | Notification of Injury or Sickness due to a Third-party Act | Immediately after notifying the police | |
| Accident Report | |||
| Signed note of assurance | |||
| Written pledge | |||
| Notice of cause of injury | |||
| When you incur high medical care costs | Request for issuance of Maximum Co-payment Certificate for Health Insurance | |
Before adjustment of medical care cost |
| Submit to: |
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