Application forms

Using the application forms
The application forms are in PDF file format. If your browser is capable of displaying PDF files, the application forms will open in a separate window. Print them from that window.
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Print each page of the application forms separately on A4 sized paper.
See here if you cannot print on A4 sized paper.
Note that applications will not be accepted if printed on the reverse side of other documents.
Carefully read the notes before filling out the forms.
Where to submit the forms varies depending on the document mark (). Check “Where to submit the forms”?below before submitting any forms.

Insurance card and application-related forms
Benefit and claims-related forms
Where to submit the forms

Insurance card and application-related forms

form	example
Notification of Health Insurance Dependent (Change)(A4)	Example
Certificate of income verification by the employer(A4)
Notification of Address Change of Dependents(A4)	Example
Notification of Name Change(A4)	Example
Application Form for Reissue of Health Insurance Card(A4)	Example
Notification of Health Insurance Card Loss(A4) * For use when you cannot return your health insurance card upon leaving your employer or changing your name, because it has been lost.
Notification of Eligibility/Ineligibility for Exemption from Long-Term Care Insurance(A4)
Application Form for Application of Standard Income Amount for Elderly Recipients(A4)
Application Form for Reissue of Elderly Benefits Card(A4)
Notification of Elderly Benefits Card Loss(A4)
Information on FY2024 System for Voluntarily and Continuously Insured Persons and Application Form for Certification as Voluntarily and Continuously Insured Person(A4)	Example
Notification of Address Change of Voluntarily and Continuously Insured Person/Dependents(A4)	Example
Notification of Name Change of Voluntarily and Continuously Insured Person/Dependents(A4)	Example
Notification Slip of Loss of Eligibility as Voluntarily and Continuously Insured Person(A4)
Application Form for Disqualification as Voluntarily and Continuously Insured Person(A4)

Benefit and claims-related forms

form	example
Application Form for Medical Care Expenses (for prepayment etc.)(A4) Application Form for Medical Care Expenses (for prosthetic equipment)(A4)	If you used your previous health insurance card If you received examination or treatment without a health insurance card If you had prosthetic equipment prepared
Application Form for Medical Care Expenses (for acupuncture, moxibustion)(A4)	Example
Application Form for Medical Care Expenses (for massage)(A4)	Example
Request for Issuance of Maximum Copayment Certificate for Health Insurance(A4)	Example
Request for Issuance of Maximum Copayment/Reduced Standard Copayment Certificate(A4)	Example
Application Form for Payment of Difference on Inpatient Meal Standard Expenses(A4)
Application for Payment of High Aggregate Cost for Long-Term Care Service(A4)	Example
Application Form for Payment of High-Cost Medical Care Benefits (Outpatient Annual Total) /Issue of Copayment Certificate(A4)	Sample completed form (application for outpatient annual total payment): with no other health insurance Sample completed form (application for outpatient annual total payment): with other health insurance Sample completed form (application for issue of copayment certificate)
[Traffic accidents] Notification of Injury or Sickness Due to a Third-party Act <four sheets>(A4) * If you cannot submit the traffic accident certificate Statement of Reasons for Inability to Submit a Traffic Accident Certificate(A4)	[Traffic accidents] Sample completed form (Notification of Injury or Sickness Due to a Third-party Act) * If you cannot submit the traffic accident certificate Sample completed form (Statement of Reasons for Inability to Submit a Traffic Accident Certificate)
[Other than traffic accidents] Notification of Injury or Sickness Due to a Third-party Act <three sheets>(A4)	[Other than traffic accidents] Sample completed form (Notification of Injury or Sickness Due to a Third-party Act)
Claim for Childbirth and Childcare Lump-sum Grant(A4)	Sample completed form (when using system of direct payment) Sample completed form (when not using system of direct payment)
Claim for Childbirth and Childcare Lump-sum Grant (for application in advance)<two sheets> (A4)	Example
Claim for Maternity Allowance(A4)	Example
Claim for Injury and Illness Allowance <three sheets>(A4)	Example
Health Insurance Injury and Sickness Allowance First Claim Report(A4)* Attach to first claim only	Example
Claim for Funeral Expenses(A4)	Example (Insured person) Example (Dependents)
Application Form for Overseas Medical Care Expenses(A4) Medical Treatment Details /Itemized Receipt(A4) Letter of Consent to Inquiries with Overseas Medical Care Institutions etc. on Details of Treatment(A4)	Example
Application Form for Certificate Issued for Specified Disease Treatment(A4)	Example
[Claiming transportation expenses] Application Form for Transportation Expenses(A4)	Example

Where to submit the forms

Submit forms indicated by the mark directly to the Recruit Health Insurance Society.

Submit forms indicated by the mark to the following parties (employers’ sections in charge of social insurance operations).

Subject persons:	Submit to:
Those whose health insurance card codes are 1, 30, 51, 57, 60, 62, 67, 71, 75, 78, 82, 83, or 90	Otsuki Office Site: Ginza Daiei Building 4F, Ginza Daiei Building, 1-16-7 Ginza, Chuo-ku, Tokyo Tel.: 050-1754-6407
Dispatched staff whose health insurance card code is 25:	SS Dept. Check by telephone before submitting. Tel.: 0120-545-106
Voluntarily and Continuously Insured Persons whose health insurance card code is 99. *1	The Health Insurance Society Submit to the Recruit Health Insurance Society address above in the same way as for forms indicated by the ?mark.
Current members of the Recruit Health Insurance Society other than those above	To each employer　Section in charge of personnel or social insurance operations
Those requesting to continue to receive Injury and Illness Allowance after leaving employment *1	The Health Insurance Society Submit to the Recruit Health Insurance Society address above in the same way as for forms indicated by the ?mark.

*1 Where to submit the form for Injury and Illness Allowance varies with the claim period.
If the claim period for Injury and Illness Allowance includes a period prior to leaving employment, check with or submit the form to the employer’s section in charge.

Example 1: Eligibility lost on January 1, 2019, claim period January 1 ? 31, 2019 → Submit directly to the Recruit Health Insurance Society staff in charge.
Example 2: Eligibility lost on January 1, 2019, claim period December 15, 2018 ? January 14, 2019
→ Certification by the employer is required on the application form, since the claim period includes a period prior to loss of eligibility.
Submit to the employer’s staff in charge, in the same way as for forms indicated by the mark above.

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