Application Forms
Application Forms
Please download, print and use any relevant application form available here.
Forms Related to Application, an Eligibility Confirmation Document
| No. | Application Form | Document | Completed Sample | Submission |
| Notification of Change of Dependents (Addition) | PDF |
Completed Sample |
Currently employed
Submit to the person in charge of health insurance at the company Voluntarily and Continuously Insured Persons Mercari Health Insurance Association Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051 |
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| Dependent Certification Record | PDF |
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| Written Oath in Regard to Dependent Certification | PDF |
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| Employment Conditions Certificate | PDF |
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| Notification of Change of Dependents (Removal) | PDF |
Completed Sample |
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| Application for Certification of Date of Status Acquisition or Loss | PDF |
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| Application for Reissuance of Health Insurance Card, Eligibility Confirmation Document or Elderly Beneficiary Health Insurance Card Due to Loss/Damage | PDF |
Completed Sample |
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| Notification of Change of Insured Person Name | PDF |
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| Application for (Re)issuance of Eligibility Confirmation Document | PDF |
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| Application form for canceling registration of the use of Individual Number Card as a Health Insurance card | PDF |
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| Application for Issuance of Eligibility Certificate for Ceiling-Amount Application | Digital Application System |
Currently employed
Submit to the person in charge of health insurance at the company Voluntarily and Continuously Insured Persons Mercari Health Insurance Association Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051 |
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PDF |
Completed Sample |
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| Application for Issuance of Certificate of Medical Treatment for Specified Diseases | PDF |
Completed Sample |
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| Notification for Acquisition of Eligibility as an Insured Person with Optional and Continued Insurance | PDF |
Completed Sample |
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| Application for Forfeiture of Status as an Insured Person with Optional Continued Insurance | PDF |
Completed Sample |
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Submission for application forms 1 through 10
Currently employed
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submission for application forms 11 through 14
Currently employed
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Forms Related to Benefits
| No. | Application Form | Document | Completed Sample | Submission |
| Application for Injury and Illness Allowance and Additional Benefits | PDF |
Completed Sample |
Currently employed
Submit to the person in charge of health insurance at the company Voluntarily and Continuously Insured Persons Mercari Health Insurance Association Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051 |
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| Information Disclosure Consent Form | PDF |
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| Application for Childbirth Allowance and Additional Benefits | PDF |
Completed Sample |
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| Application for Payment of Burial Fees (Expenses) and Additional Benefits | PDF |
Completed Sample |
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| Application for the Childbirth and Childcare Lump-sum Allowance and Additional Benefits (No Use of the Direct Payment System) | PDF |
Completed Sample |
Currently employed
Submit to the person in charge of health insurance at the company Voluntarily and Continuously Insured Persons Mercari Health Insurance Association Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051 |
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| Application for Payment of the Childbirth and Childcare Lump-sum Allowance (Substitute Payee System) | PDF |
Completed Sample |
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| Application for Payment of Medical Care Costs (Advance Payment) | PDF |
Completed Sample |
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| Application for Payment of Medical Care Costs (For Therapeutic Devices, Therapeutic Eyeglasses, etc.) | PDF |
Completed Sample |
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| Documents to be attached to the application for payment of medical care costs for therapeutic devices (therapeutic device manufacturing confirmation form) | PDF |
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| Application for Payment of Medical Care Costs (for Acupuncture and Moxibustion) | PDF |
Completed Sample |
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| Application for Payment of Medical Care Costs (Massages) | PDF |
Completed Sample |
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| Application for Payment of Medical Care Costs (Overseas Medical Expenses) | PDF |
Completed Sample |
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| Attending Physician's Statement (Form A) (Overseas) | PDF |
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| Itemized Receipt (Form B) (Overseas) | PDF |
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| Attending Physician's Statement (Dental) (Overseas) | PDF |
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| Investigation Authorization Agreement for Overseas Medical Care Costs (Overseas) | PDF |
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Submission
for application forms 15 through 18
for application forms 15 through 18
Currently employed
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submission
for application forms 19 through 30
for application forms 19 through 30
Currently employed
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submit to the person in charge of health insurance at the company
Voluntarily and Continuously Insured Persons
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Forms Related to Healthcare Services
| No. | Application Form | Document | Completed Sample | Submission |
| Application Form for Health Checkup Subsidy Payment | PDF |
Completed Sample |
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051 |
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※If you do not have the health checkup questionnaire, please download it from the link below and submit it.
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| Application for Subsidy of Influenza Vaccination Cost | Digital Application System |
Value HR Co., Ltd.
Seto Operation Center Influenza Vaccination Receptionist 108 Parti Seto, 45 Sakae-cho, Seto-shi, Aichi 489-0044, Japan |
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PDF |
Completed Sample |
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Submission
for application form 31
for application form 31
Mercari Health Insurance Association
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Yoyogi East 5F 5-23-5 Sendagaya, Shibuya-ku, Tokyo 151-0051
Submission
for application form 32
for application form 32
Value HR Co., Ltd. Seto Operation Center Influenza Vaccination Receptionist
108 Parti Seto, 45 Sakae-cho, Seto-shi, Aichi 489-0044, Japan
108 Parti Seto, 45 Sakae-cho, Seto-shi, Aichi 489-0044, Japan