List of application forms

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 the application forms to the Health Insurance Society if you are a Takeda Pharmaceutical Company Limited employee or a Voluntarily and Continuously Insured Person. Submit to your employer’s person in charge of health insurance administration if you are an employee of an establishment other than Takeda Pharmaceutical Company Limited.

Title of form	Download notice/application form	Download example of completed notice/form
Application Form for Reissue of Health Insurance Card (Card loss/Damage)	Form	Example of completed form
Notification of Health Insurance Card Loss	Form	Example of completed form
Notification of Loss of Eligibility as Health Insurance Dependent	Form	Example of completed form
Notification of Loss of Eligibility as Health Insurance Dependent (for period of receipt of unemployment benefits)	Form	Example of completed form
Application Form for Dependent Certification	Form	Example of completed form
Unemployment Benefits Receipt Confirmation Form	Form	Example of completed form
Unemployment Benefits Waiver Confirmation Form	Form	Example of completed form
Survey Form of Livelihood Dependency on Insured Person	Form	Example of completed form
Notice of Change to Registered Health Insurance Information	Form	Example of completed form
Application Form for Certification as Health Insurance Voluntarily and Continuously Insured Person	Form	Example of completed form
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 of completed form
Application form for reissue of specified health diagnosis examination ticket/health guidance ticket	Form	Example of completed form

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 of completed form
Letter of Consent to Investigation	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 of completed form
Application Form for Approval of Transportation	Form	Example of completed form
Application Form for Transportation Expenses	Form	Example of completed form
Claim for Injury and Sickness Allowance/Additional Sum	Form	Example of completed form
Claim for Maternity Allowance/Additional Sum	Form	Example of completed form
Claim for Childbirth and Childcare Lump-sum Grant (Insured Person, Dependent)	Form	Example of completed form
Claim for Funeral Expenses/Funeral Costs (Insured Person, Dependent)	Form	Example of completed form
Application for Payment of High-Cost Long-Term Care Combined Expenses	Form	Example of completed form
Application Form for Insurance of Copayment Certificate (High-Cost Long-Term Care Combined Expenses)	Form	Example of completed form
Health Insurance Application for Payment of Benefits (Outpatient Annual Aggregate)/Issuance of Copayment Certificate for High-cost Medical Expenses	Form	Example of completed form
Application Form for Certificate Issued for Specific Disease Treatment	Form	Example of completed form

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

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 of completed form