[For patients and designated medical institutions] Specific medical expenses (designated incurable disease) Out-of-pocket limit management slip

After printing the following PDF file, paste it on the self-pay upper limit management slip on the recipient ID.
(If you glue the entire surface, you will not be able to see the self-pay upper limit management slip that the medical institution has described so far.
Please paste the glue only a few centimeters from the top so that you can see the self-pay upper limit management slip below it. )
　

　
[Request to Patients]
・The co-payment limit management slip is written by the medical institution. (The patient should not describe it.)
・Please see the self-pay upper limit management slip each time you make a payment at the counter.
Please confirm whether "the amount to be paid at the counter" and "[self-pay] stated by the hospital (including [self-pay cumulative amount (monthly)")" match. ※。
※If you use other Medical Certificate together, you may not have to pay yourself, but you will be asked to fill out the co-payment limit management slip as usual.
Also, even if you are in social security, please include the [Date, Designated Medical Institution Name, Total medical expenses (100%)] column.
If the medical institution uses the recipient ID with the description incorrectly (for example, omission, calculation error, etc.),
Out-of-pocket expenses may increase, or calculation errors may occur at the medical institutions listed below.
　

About mention method such as self-pay upper limit management vote pertaining to specific medical expenses (for designated medical institution) (PDF: 791KB) (April, 2024 version)
　
[Please ask a medical institution]
・When describing the The Long-term Care Insurance service portion, please indicate the amount of 1 yen in the [Total amount of medical expenses (100%)] column and the [Out-of-pocket amount] column rounded to the nearest 10 yen.
・If you pay and claim service costs in the following month for home-visit nursing, etc., you may collectively list them in one stage in the service provision month.
・Since it may be necessary when requesting a refund for a specific medical expenses, Yokohama City will continue to ask you to enter the medical expenses total amount (100%) column for the month exceeds 50,000 yen.
・From January 2021, please omit the seal on the [collection mark] and [confirmation mark] of the self-pay upper limit management slip.
　

・Those who have reached the maximum monthly co-payment limit: Even after the monthly co-payment limit is reached, please indicate the medical expenses (including The Long-term Care Insurance) related to designated incurable disease within that month in the [date, designated medical institution name, total medical expenses (100%)] column. [Co-payment / Cumulative amount (monthly)] Please draw a diagonal line in the column.
　
・If you use other Medical Certificate together: Even if you do not have a co-payment, please describe it in the same way as a co-payment patient. When you reach the maximum monthly co-payment limit, please draw a diagonal line in the following [co-payment / co-payment cumulative amount (monthly)] column.
　
・For social security, please indicate the [Date, Designated Medical Institution Name, Total medical expenses (100%)] column. [Co-payment / Cumulative amount (monthly)] Please draw a diagonal line in the column. In addition, please do not list meal charges and living medical expenses at the time of hospitalization in self-pay upper limit management vote.
　

・Please fill in the self-pay upper limit management slip each time you visit. However, if you collect the monthly expenses required for hospitalization for hospitalization in the following month, you may collectively list them in one step of the copayment upper limit management slip for the hospitalization month.
In addition, please be careful not to list the amount of the standard amount of dietary treatment and the standard amount of living treatment at the time of hospitalization are not included in [Total medical expenses (100%)] or [Out-of-pocket amount].
・If you use other public expenses together, there may be no out-of-pocket expenses, but please indicate the amount you should originally pay on the out-of-pocket upper limit management slip (confirmed with the Ministry of Health, Labor and Welfare).
・Please fill in the following fields with special attention to parentheses.
[Date] ・・ ・ Describe the date on which the patient used the medical institution. (It is not the day when the co-payment was collected.)
[Name of designated medical institution] ・・ ・ Enter the name of the medical institution (the name can also be stamped). (Please do not charge the amount in the [Total medical expenses (100%)] column.)
[Total medical expenses (100%)] ・・ ・ Describe the total amount of the date of use. (It's not a score. It may be necessary for certain medical expenses refunds. Please continue the description even after exceeding 50,000 yen. )
Out-of-pocket expenses ・・ ・ ・ If the amount paid by the patient at the counter or the maximum monthly co-payment is reached, indicate that amount. (The amount charged for patients with a 30% burden will be 20%. In addition, after reaching the maximum monthly co-payment limit, draw a diagonal line as in the example of entry on the recipient ID. )
In particular, please make sure that the co-payment column and the designated incurable disease medical expenses billed on that day are the same and that there are no omissions. (If there are any omissions or errors in the upper row, an error will occur when the monthly co-payment limit is reached in the lower row.)
Cumulative Out-of-pocket amount (monthly) ・・ ・ Enter the amount paid by the patient at the counter of each designated medical institution until the total monthly co-payment limit is reached. (After reaching the maximum monthly co-payment limit, draw a diagonal line.)
　

・Please fill in the self-pay upper limit management slip each time you visit. However, if multiple visits are settled and claimed in the following month, they may be collectively listed on the last day of the service provision month.
・If you use other public expenses together, there may be no out-of-pocket expenses, but please indicate the amount you should originally pay on the out-of-pocket upper limit management slip (confirmed with the Ministry of Health, Labor and Welfare).
・Please fill in the following fields with special attention to parentheses.
[Date] ・・ ・ Describe the date on which the patient used the medical institution or service. It is not the day when the co-payment was collected. In addition, if you visit or visit multiple times, please indicate on the last day of the month end of the service provision month. )
[Name of designated medical institution] ・・ ・ Enter the name of the medical institution (the name can also be stamped). (Please do not charge the amount in the [Total medical expenses (100%)] column.)
[Total medical expenses (100%)] ・・ ・ Describe the total amount of the date of use. (It's not a score. It may be necessary to confirm the specific medical expenses. Please continue the description even after exceeding 50,000 yen. )
Out-of-pocket expenses ・・ ・ ・ When the amount paid by the patient or the maximum monthly co-payment is reached, indicate that amount. (The amount charged for patients with a 30% burden will be 20%. In addition, after reaching the maximum monthly co-payment limit, draw a diagonal line as in the example of entry on the recipient ID. )
In particular, please make sure that the amount of your co-payment column is the same as the designated incurable disease medical expenses on that day, and that there are no omissions. (If there are any omissions or errors in the upper row, an error will occur when the monthly co-payment limit is reached in the lower row.)
Cumulative Out-of-pocket amount (monthly) ・・ ・ Enter the amount paid by the patient at the counter of each designated medical institution until the total monthly co-payment limit is reached. (After reaching the maximum monthly co-payment limit, draw a diagonal line.)
　

In Yokohama City, we have posted many inquiries from medical institutions, so please read them together.
For more information, look here. ➡ FAQs