Application form (For general insured person)

Forms related to health insurance eligibility and coverage
Forms related to insurance benefits and claims
Forms related to subsidies for health checkups, etc.

Forms related to health insurance eligibility and coverage (For general insured person)

Name of Application form	Application support system	Application Form	Example
T-002　Notification of Change (Correction) of Name, Date of Birth, etc. T-011　Notification of Health Insurance Dependent Change (Increase) T-012　Notification of Health Insurance Dependent Change (Removal) T-022　Notification of Change (decrease) of Dependents and Address (For those applicable to the Medical Care System for the Advanced Elderly) T-501　Notification of Overseas Posting Exempt from Long-term Care Insurance/Return to Japan (for Overseas Residents, etc.)	ー	To authentication page
T-003　Notification of (Change of) Address of Insured Person	Log in	Application Form	Example
T-004　Benefit Transfer Account (Change) Form	Log in	Application Form	Example
T-005　Notification of Personal Number (My Number)	Log in	Application Form	Example
T-013　Notification of status in connection with application for dependents	Log in	Documents to attach	Example
T-015　Agreement for recognition of dependents		Documents to attach	Example
T-016　Application for recognition of dependency due to receipt or non-receipt of unemployment benefits		Documents to attach	Example
T-017　Request for certificate of items stated in resident register		Documents to attach	Example
T-018　Request for certificate of employment		Documents to attach	Example
T-019　Prospective income certificate		Documents to attach	Example
T-008　Application for Canceling Registration of Individual Number Card Used as a Health Insurance Card	ー	Application Form	Example
T-020　Report on Unemployment/Lack of Income	ー	Application Form	Example
T-102　Notification of non-return of insured person's card for those who lost eligibility/Eligibility Verification Certificate	ー	Application Form	Example
T-211　Application for Eligibility, Approval Notice, and Pre-Application Check Sheet for Voluntarily and Continuously Insured Persons T-212　Approval notice T-241　Pre-Application Check Sheet	Log in	Application Form	Example
T-221　Application for Eligibility, Approval Notice, Pre-Application Check Sheet, and Annuity Certificate (Sample) for Special-Case Retired Insured Persons T-222　Approval notice T-240　Pre-Application Check Sheet Annuity Certificate (Sample) * If you are re-enrolling in the Hitachi health insurance society from another health insurance society, the application form is different. Please contact the Hitachi health insurance society.	Log in	Application Form	Example
T-401　Request for Certificate of Eligibility/Loss of Eligibility	Log in	Application Form	Example

Consult with the Health Insurance Society Operations (Application) if you have gender identity disorder and would prefer not to have the name or gender from your family register indicated on your Notice of Eligibility Information or Eligibility Verification Certificate.

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Forms related to insurance benefits and claims (For general insured person)

Name of Application form	Application support system	Application Form	Example
K-601　Request for issuance of Maximum Co-payment Certificate for Health Insurance	Log in	Application Form	Example
K-501　Application for Certification of Benefits	ー	Application Form	Example
K-001　Claim for Medical Care Expenses (Advance Payment, Prosthetic Equipment, etc.) * This application form cannot be used when you have paid the entire cost of medical checkup in advance. Click here when you have paid for the health checkup.	Log in	Application Form	Example (advance payment) Example (When you receive a claim for medical expenses from another health insurance and make a refund) Example (Prosthetic equipment) Example (Eyeglasses for the treatment of amblyopia in children)
K-002　Detailed receipt (examination and treatment)	ー	Documents to attach	ー
K-002　Detailed receipt (examination and treatment) (Dental)	ー	Documents to attach	ー
K-002　Receipt (dispensing) statement	ー	Documents to attach	ー
K-007　Certificate of instruction to fabricate prosthetic equipment and fitting thereof	ー	Documents to attach	ー
K-008　Prescription for eyeglasses prepared to treat juvenile amblyopia or similar conditions	ー	Documents to attach	ー
K-003　Claim for Medical Care Expenses (for Massage)	ー	Application Form	Example
Application Form for Medical Care Expenses (for Massage) * Obtain an Application Form for Medical Care Expenses from the massage clinic where you received treatment.	ー	ー	ー
K-005　 (Physician’s) Letter of Consent (for Massage)	ー	Documents to attach	ー
K-010　Receipt Submittal Sheet	ー	Documents to attach	ー
K-004　Claim for Medical Care Expenses (for Acupuncture/Moxibustion)	ー	Application Form	Example
Application Form for Medical Care Expenses (for Acupuncture/Moxibustion) * Obtain an Application Form for Medical Care Expenses from the acupuncture clinic where you received treatment.	ー	ー	ー
K-009　(Physician’s) Letter of Consent (for Acupuncture/Moxibustion)	ー	Documents to attach	ー
K-010　Receipt Submittal Sheet	ー	Documents to attach	ー
K-011　Application Form for Overseas Medical Care Expenses	Log in	Application Form	Example
K-012　Medical Consultation Details（statement） (For dental)	ー	Documents to attach	ー
K-013　Medical Consultation Details（statement）	ー	Documents to attach	ー
K-014　Overseas Medical Care Expenses (Japanese translation)	ー	Documents to attach	ー
K-031　Claim for Injury and Sickness Allowance	Log in	Application Form	Example
K-035　Space for doctor's opinion/space for employer certification (for Injury and Sickness Allowance)	ー	Documents to attach	ー
K-053　Consent form (for Injury and Sickness Allowance) * Please read the "Notes" on the consent form and attach it if applicable.	ー	Documents to attach	ー
K-052　Health Insurance Coverage Survey Form * Please read the "Notes" on the survey form and attach it if applicable.	ー	Documents to attach	Example
K-032　Claim for Maternity Allowance	Log in	Application Form	Example
K-036　Space for doctor's opinion/space for employer certification (for Claim for Maternity Allowance)	ー	Documents to attach	ー
K-033　Claim for Childbirth and Childcare Lump-sum Grant	ー	Application Form	Example (If the insured person has given birth) Example (If a dependent has given birth)
K-054　Health Insurance Coverage Survey Form (for application for payment of Childbirth and Childcare Lump-sum Grant)	ー	Documents to attach	ー
K-039　Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf)	ー	Application Form	Example (If the insured person has given birth) Example (If a dependent has given birth)
K-054　Health Insurance Coverage Survey Form (for application for payment of Childbirth and Childcare Lump-sum Grant)	ー	Documents to attach	ー
K-037　Claim for Funeral Expenses/Funeral Costs	Log in	Application Form	Example (Death of an insured person) Example (Death of a dependent)
K-038　Notification of Succession to Rights	ー	Application Form	Example (Inheritance by death of the insured person)
K-021　Application Form for Transportation Expenses	ー	Application Form	Example
K-022　Application Form for Approval of Transportation/ Notification of Transportation	ー	Application Form	Example
K-101　Application Form for issue of Certificates Issued for Specific Disease Treatment	ー	Application Form	Example
K-201　Application form for certification of application of the maximum amount and reduction of the standard burden amount	ー	Application Form	Example
K-006　Request form for medical treatment expenses (for application for payment of the difference in the standard amount for meal treatment expenses)	ー	Application Form	Example
K-401　Application for Loans for Childbirth Expenses	ー	Application Form	Example
K-050　Application form for payment of high-cost combined long-term care treatment cost	ー	Application Form	Example
K-051　Application for payment of high-cost combined long-term care treatment expenses, and application for issuance of a certificate of co-payment	ー	Application Form	Example

Consult with the Operations Dept. (Benefits) of the Health Insurance Society if you have gender identity disorder and have changed the gender or name indicated on your Notice of Eligibility Information or Eligibility Verification Certificate and would also prefer to change the corresponding description on the Certificate of Application of Maximum Copayment Amount or other documents.

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Procedures related to subsidies for health checkups, etc. (For general insured person)

Contents	Name of Application form
When you have paid the entire cost of the health checkup in advance.
(1) Employees	Application support system Request for subsidy for health checkups （Connect to Hitachi Group Intranet.）
(1) Employees	If you are unable to use the application support system Request for Subsidy for Health Checkups (Examinations) (for employee individual reimbursements) Example Specific Health Checkup Questionnaire
(2) Dependents, Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person	Request for Subsidy for Health Checkups (Examinations) (for Dependents, Voluntarily and Continuously Insured Person, Special-Case Retired Insured Person individual reimbursements)

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