About application documents of medical system for elder senior citizens

For more information, please visit the link below. Please note that not all applications are posted.

Last Updated January 24, 2024

<If you are coming to the agency, please come to Insurance and Pension Division (5th window on the first floor).＞

１．Documents related to re-issuance

①Application for re-grant of insured person identification (PDF: 58KB)

２．Application for Limit Application / Standard Burden Reduction Certification

①Application for limit application certification (Active average income earners 1 and active average income earners 2) (PDF: 99KB)

②Limit application, standard burden reduction authorization application (low-income person 1, low-income person 2) (PDF: 118KB)

※The application form varies depending on the category.
[Note 1] Only active earners (taxable income of less than 6.9 million yen) and households exempt from residence tax are required to apply the limit application certificate. For other people, presenting your insurance card to a medical institution will result in the window burden up to the copayment limit according to the burden ratio, so you do not need a limit application certificate.
[Note 2] Please refer to the link for details such as the burden category.

About income category (outside site)

※"1 Petition for application and receipt of benefit expenses" is a form required when the insured person dies.
　If another household becomes the heir, certificate of family register etc. is required.

You may need a separate PDF reader to open a PDF file.
If you do not have it, you can download it free of charge from Adobe.
To download Adobe Acrobat Reader DC