When making an inquiry, you will need to provide your health insurance ｍember code / number.
* See here to check your health insurance ｍember code / number.

See here for inquiries.

Application forms

Lists

Health insurance eligibility and application-related forms
Benefit and claims-related forms

Health insurance eligibility and application-related forms

1. Notification of Health Insurance Dependent Change
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. Application Form for Issue/Reissue of Health Insurance Eligibility Certificate
Example
3-1. Application Form for Reissue of Notice of Eligibility Information
Example
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.
3-2. Notification of Health Insurance Card Loss
Example
Those who have lost their insurance card must submit this declaration.
3-2-1. Notification of Health Insurance Eligibility Certificate Loss
Example
3-3. Return form for Health Insurance Eligibility Certificate

4. Notification of Insured Person Change (Correction)
Example

5. Application Form for Certification as Voluntarily and Continuously Insured Person

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

7. Application Form for New Registration of Health Insurance Individual Number (My Number)
Example

7-1.Notification of Change of Health Insurance Individual Number (My Number)
Example

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

Benefit and claims-related forms

8. Application Form for Maximum Copayment Certificate

* 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. Application Form for Medical Care Expenses/ Additional Sum
Example (Charges forward) Example (Therapeutic orthoses)
Example (Therapeutic eyeglasses) Example (Overseas medical care expenses)

10. Claim for Childbirth and Childcare Lump-sum Grant Partial Payment (Difference)

11‐1. Claim for Childbirth and Childcare Lump-sum Grant (with copy of receipt attached)
11‐2. Letter of Consent for Confirming Details of Childbirth Outside of Japan

12. Claim for Maternity Allowance

13. Claim for Funeral Expenses/Funeral Costs/ Additional Sum

14-1. Application Form for Injury and Sickness Allowance/ Additional Sum
Example
14-2. Daily Life and Medical Treatment Status Report (for persons leaving employment)

15. Application Form for Approval of Transportation/Notification of Transportation

16-1. Attending Physician’s Statement for overseas medical care expenses (for medical) Form A and its Japanese translation (A)
16-2. Attending Dentist's Statement for overseas medical care expenses (for dental) Form C and its Japanese translation (C)
16-3. Itemized Receipt for overseas medical care expenses Form B and its Japanese translation (B)

* For overseas medical care expenses applications, “9. Application Form for Medical Care Expenses/ Additional Sum” is also required.

17. Agreement of Authorization for Overseas Medical Care Expenses Investigation

18. Accident (Third-party Act) Report

19. Notification of Injury or Sickness due to a Third-party Act

20. Accident Circumstances Report

21. Memorandum (Third-party Act)

22. Pledge (Third-party Act)