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Long-term care insurance related

Last updated: May 10, 2024

Please print it out and use it.
Note: Plain paper is recommended for print paper, and A4 is recommended for print size.
Thermal paper for thermal printers cannot be accepted.

Download various forms (for businesses)

Click here for the form for businesses

Long-term care/support certification application (PDF format)

File Download Opens in a new window.Long-term care insurance long-term care, support required certification application (both sides printing) (PDF: 495KB)

File Download Opens in a new window.(entry example) long-term care insurance long-term care, support required certification application (PDF: 684KB)

File Download Opens in a new window.Long-term care insurance (certification of need for long-term care and support) cancellation application (PDF: 76KB)

File Download Opens in a new window.Questionnaire (PDF: 275KB) for chief physician written statement of opinion making

Application for long-term care/support certification (word format)

File Download Opens in a new window.Long-term care insurance long-term care, support required certification application (both sides printing) (Word: 34KB)

File Download Opens in a new window.Long-term care insurance (certification of need for long-term care/support) cancellation application form (Word: 20KB)

File Download Opens in a new window.Questionnaire (Word: 37KB) for chief physician written statement of opinion making

Other forms (PDF format)

File Download Opens in a new window.Application for reissue of nursing care insurance certificate, etc. (PDF: 296KB)

File Download Opens in a new window.Long-term care insurance burden limit authorization application (PDF: 157KB)

File Download Opens in a new window.Address ground exception application, change, end notification form (PDF: 160KB)

File Download Opens in a new window.[For individuals] Personal information disclosure request form (PDF: 300KB)

File Download Opens in a new window.Notification of destination setting for nursing care insurance-related documents (PDF: 97KB)

File Download Opens in a new window.Proxy (PDF: 132KB) about care insurance-related procedure

Other forms (Word/Excel format)

File Download Opens in a new window.Identification of long-term care insurance person insured (re) grant application (Excel: 31KB)

File Download Opens in a new window.Long-term care insurance burden limit authorization application (Excel: 67KB)

File Download Opens in a new window.Address ground exception application, change, end notification form (Excel: 35KB)

File Download Opens in a new window.[For individuals] Personal information disclosure request form (Excel: 18KB)

File Download Opens in a new window.Notification of destination setting for nursing care insurance-related documents (Excel: 42KB)

File Download Opens in a new window.Power of attorney (Word: 13KB) about care insurance-related procedure

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Inquiries about this page

Elderly Welfare Division, Welfare Department, Inagi City
2111 Higashi Naganuma, Inagi City, Tokyo
Phone: 042-378-2111 Fax: 042-377-4781

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Elderly Welfare Division

  • Long-term care insurance related

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Inagi City Hall

2111 Higashi Naganuma, Inagi City, Tokyo 206-8601
Open agency hours: 8:30 a.m. to 5:00 p.m. Main phone number: 042-378-2111 Fax: 042-377-4781
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