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List of application forms

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List of application forms

List of application forms

INDEX

Forms related to health insurance cards and eligibility
Forms related to benefits and claims
Forms related to third-party actions (including traffic accidents)
Forms related to traffic accidents caused by your own negligence

Forms related to health insurance cards and eligibility

Submit to the Health Insurance Society if you are a Takeda Pharmaceutical Company Limited employee or the section at your company responsible for health insurance administration if you are not a Takeda Pharmaceutical Company Limited employee.

Title of form	Download notice/application form	Download example of completed notice/form	Notes
Application Form for Issue/Reissue of Eligibility Verification Certificate	Form	Example
Application Form for Reissue of Notice of Eligibility Information	Form	Example
Notification of Health Insurance Card / Eligibility Verification Certificate Loss	Form	Example
Notification of Loss of Eligibility as Health Insurance Dependent	Form	Example	Takeda Pharmaceutical Company Limited employees and Voluntarily and Continuously Insured Persons should attach return envelopes.
Notification of Loss of Eligibility as Health Insurance Dependent (for period of receipt of unemployment benefits)	Form	Example
Application Form for Dependent Certification	Form	Example	Takeda Pharmaceutical Company Limited employees and Voluntarily and Continuously Insured Persons should attach return envelopes.
Unemployment Benefits Receipt Confirmation Form	Form	Example
Unemployment Benefits Waiver Confirmation Form	Form	Example
Survey Form of Livelihood Dependency on Insured Person	Form	Example
Notice of Change to Registered Health Insurance Information	Form	Example	Takeda Pharmaceutical Company Limited employees and Voluntarily and Continuously Insured Persons should attach return envelopes.
Application Form for Certification as Health Insurance Voluntarily and Continuously Insured Person	Form	Example
Application Form for Decertification as Health Insurance Voluntarily and Continuously Insured Person	Form	-
Notification of Long-term Care Insurance (Qualification/Disqualification) (Insured Person)	Form	Example

Forms related to benefits and claims

Title of form	Download notice/application form	Download example of completed notice/form
Claim for Medical Care Expenses (Insured Person, Dependent)	Form	Example
Letter of Consent to Investigation (Overseas Medical Care)	Form	-
Dental consultation details (for dental care)	Form	-
Medical consultation details (for non-dental care)	Form	-
Itemized receipt	Form	-
Request for Issuance of Certificate of Application of Maximum Copayment Amount	Form	Example
Application Form for Approval of Transportation	Form	Example
Application Form for Transportation Expenses	Form	Example
Claim for Injury and Sickness Allowance/Additional Sum	Form	Example
Claim for Maternity Allowance/Additional Sum	Form	Example
Claim for Childbirth and Childcare Lump-sum Grant (Insured Person, Dependent)	Form	Example
Letter of Consent to Investigation (Overseas Childbirth)	Form	-
Claim for Funeral Expenses/Funeral Costs (Insured Person, Dependent)	Form	Example
Application for Payment of High-Cost Long-Term Care Combined Expenses	Form	Example
Application Form for Insurance of Copayment Certificate (High-Cost Long-Term Care Combined Expenses)	Form	Example
Health Insurance Application for Payment of Benefits (Outpatient Annual Aggregate)/Issuance of Copayment Certificate for High-cost Medical Expenses	Form	Example
Application Form for Certificate Issued for Specific Disease Treatment	Form	Example

Forms related to third-party actions (including traffic accidents)

Title of form	Download notice/application form	Download example of completed notice/form
Notification of Injury or Sickness due to a Third-party Act	Form	Example
Written Pledge	Form	Example
Interim Report on Injury or Sickness due to a Third-party Act	Form	Example
Notice of Completion of Treatment	Form	Example
Application Form for Exemption from Refunding of Health Insurance Benefits	Form	Example

Forms related to traffic accidents caused by your own negligence

Title of form	Download notice/application form	Download example of completed notice/form
Notice of Accident Due to Own Negligence	Form	Example