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Insurance card and application-related forms
Benefit and claims-related forms

Address to submit an application

Health Insurance Association for Amazon Japan Employees
Section in charge of Health Insurance Association for Amazon Japan Employees Health Insurance Administration Center, Value HR Co., Ltd. S-FRONT Yoyogi, 5-21-12 Sendagaya, Shibuya-ku, Tokyo 151-0051, Japan TEL:03-5357-7555 e-mail：info@kenpo-info.jp
Amazon Japan G.K. HR Services
6F, 3-28-25, Higashishinagawa, Shinagawa-ku, Tokyo, 140-0002, Japan TEL:03-6367-4000
SATO Labor and Social Security Attorney Office
SATO Labor and Social Security Attorney Office, Sapporo Office Attn: In charge of Amazon Japan 1-33, Kita 5 Jo Higashi 8 Chome, Higash-ku, Sapporo-shi, Hokkaido, 065-8631, Japan

Insurance card and application-related forms

Form	Example	Submit documents to
※ Adding a family member Notification of Health Insurance Dependent Change(Add dependents) (A4) Status of dependents(A4) Certificate of Employment(A4) Dependent Certification Pledge(A4) Statement that annual income will not exceed 1.3 million yen (A4) ※ See the Appendix List of Documents to be Submitted for Certification of the Insured Person Taxation (Tax Exemption) and Residence Certificates Obtainedat Municipal Government Offices	Example (Notification of Dependent Change) Example (Status of dependents)	SATO Labor and Social Security Attorney Office If you can connect to Amazon's network environment ⇒Please submit using the "TICKET" system. For details on how to submit, please refer to Inside Amazon . * Amazon network environment is required. Others ⇒Please send the docments by post to SATO Labor and Social Security Attorney Office. * If you are unable to print out the form yourself, please contact the HR Services. They will send you the documents.
※ Removing a family member Notification of Health Insurance Dependent Change (Dependent Deletion) (A4) * Attach the health insurance card(s) of the family member(s) to be removed.	Example
Application Form for Reissue of Health Insurance Card (Card loss/Damage) (A4)	Example	SATO Labor and Social Security Attorney Office If you can connect to Amazon's network environment ⇒Please submit using the "TICKET" system. For details on how to submit, please refer to Inside Amazon . * Amazon network environment is required. Others ⇒Please send the docments by post to SATO Labor and Social Security Attorney Office. * If you are unable to print out the form yourself, please contact the HR Services. They will send you the documents.
Health Insurance Insured Person / Dependent Name Change Notification (all types of changes/corrections) (A4)	Example
Application Form for Certification as Voluntarily and Continuously Insured Person(A4)	Example	Health Insurance Association for Amazon Japan Employees
Application Form for Disqualification as Health Insurance Voluntarily and Continuously Insured Person(A4)	Example
Notification of Change Regarding Recipient of Voluntary Continuation of Insurance(A4)	－
Request for Issuance of a Certificate of Eligibility for Ceiling-Amount Application(A4) Electronic Application	Example
Request for Issuance of Certificate of Treatment Received for Specified Diseases(A4)	Example
Request for certification(A4)	Example

Benefit and claims-related forms

Form	Example	Submit documents to
Application Form for Medical Care Expenses (For reimbursement of medical expenses) (A4)	Example	Health Insurance Association for Amazon Japan Employees
About the photograph of orthopedic footwear	－
Application Form for Medical Care Expenses (For therapeutic devices, therapeutic eye glasses, etc.) (A4)	－
Application Form for Medical Care Expenses (moxibustion/massage) (A4)	－
Instructison on how to claim medical insurance benefit when you see a doctor outside Japan (A4) Application Form for Overseas Medical Care Expenses (A4) Agreement of Authorization Attending Physician's Statement (Form A) Itemized Receipt (Form B) Attending Dentist Statement (Form C) Table of International Classification of Diseases for the use of Social Insurance	Example (Application Form for Overseas Medical Care Expenses)
Application Form for Overseas Medical Care Expenses and other necessary documents.zip	－
Claim Form for Disability Benefits Letter of consent for information disclosure (A4) Health insurance enrollment history report (A4)	Example Example	SATO Labor and Social Security Attorney Office (by mail)
Claim Form for Partial Payment of Lump-Sum	Example	Health Insurance Association for Amazon Japan Employees
Claim Form for Childbirth Lump-Sum Benefits Payment or Rebate (A4)	Example
Childbirth Lump-Sum Benefits Payment or Rebate (Application to receive payment as representative)(A4)	Example
Claim Form for Maternity Benefits(A4)	Example	SATO Labor and Social Security Attorney Office (by mail)
Claim Form for Burial Costs (Expenses) and Rebates(A4)	Example	If the insured person has died: Pay Services, Benefit If a family member has died: Health Insurance Association for Amazon Japan Employees
「Vaccination Subsidy for Measles, Rubella and Mumps」(A4) 「Application for Subsidies of Measles, Rubella and Mumps Vaccination」(A4)	Example	Health Insurance Association for Amazon Japan Employees
「Influenza Vaccination Subsidy」(A4) 「Application for Subsidies of Influenza Vaccination」(A4) Electronic Application	Example	Health Insurance Association for Amazon Japan Employees