Application forms

Lists

Health Insurance Eligibility and Coverage Forms
Benefit and Claim Forms

Health Insurance Eligibility and Coverage Forms

1. Health Insurance Dependent Change Notification
Example When adding (eligible) family members as dependents
Example When removing (ineligible) family members from dependent status

2-1. Statement of Financial Dependency (Newborn)
Example
2-2. Statement of Financial Dependency (Spouse)
Example
2-3. Statement of Financial Dependency (Family members other than spouse or newborn)
Example
2-4. Expected Income Certificate
2-5. Current Status Report

3. Health Insurance Eligibility Certificate (Re)issuance Application Form
Example
3-1. Health Insurance Eligibility Information Notice Reissuance Application Form
If you can access the Medical Insurance Eligibility Information Screen on Mynaportal, this application is generally not required, as the screen can be used as a substitute.
Example
3-2. Declaration of Lost Insurance Card
Example
Those who have lost their insurance card must submit this declaration.

4. Insured Person Change (Correction) Notification
Example

5. Application for Certification as Voluntarily and Continuously Insured Person

6. Declaration of Loss of Eligibility as Voluntarily and Continuously Insured Person

7. Application for Cancellation of My Number Card Health Insurance Card Registration
Example
The cancellation process takes approximately 1-2 months.

Benefit and Claim Forms

8. Health Insurance Maximum Copayment Certificate Application Form

* You cannot apply after being discharged from the hospital. Please apply in advance.
If you receive medical care using your My Number insurance card, this application is not necessary, as the process can be handled through online verification.

9. (Insured Person/Family) Medical Expenses Reimbursement/Additional Medical Benefits Application Form
Example

10. (Insured Person/Family) Childbirth and Childcare Lump-sum Grant Partial Payment (Difference) Claim Form

11. (Insured Person/Family) Childbirth and Childcare Lump-sum Grant Claim Form (with copy of receipt attached)

12. Maternity Allowance Claim Form

13. (Insured Person/Family) Funeral Expenses/Additional Funeral Expenses Claim Form

14. Injury and Sickness Allowance/Additional Injury and Sickness Allowance Claim Form
Example

15. Transfer Approval Application/Transfer Notification/Health Insurance (Insured Person/Family) Transfer Approval Application Form

16. Overseas Medical Expenses Reimbursement Application Form [A][B]

* For overseas medical expenses applications, “9. Medical Expenses Reimbursement/Additional Medical Benefits Application Form [A]” is also required.

17. Consent Form for Overseas Medical Expenses Investigation

18. Accident (Third-party Act) Report

19. Injury Due to Third-party Act Report

20. Accident Circumstances Report

21. Memorandum (Third-party Act)

22. Pledge (Third-party Act)