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Nursing care insurance related

Updated: October 1, 2024

Please print it out and use it.
Note: We recommend plain paper and A4 print size.
Thermal paper for thermal printers cannot be accepted.

Download various forms (for businesses)

Click here for the form for businesses

Application for certification of nursing care/support requirements (PDF format)

File Download Opens in a new window.Application form for nursing care insurance certification of need for nursing care or assistance (double-sided printing) (PDF: 495KB)

File Download Opens in a new window.(Example) Application form for certification of long-term care and support required under nursing care insurance (PDF: 684KB)

File Download Opens in a new window.Application for cancellation of long-term care insurance (certification of needing long-term care/support) (PDF: 76KB)

File Download Opens in a new window.Questionnaire for preparing the attending physician's opinion (PDF: 275KB)

Application for certification of nursing care/support requirements (Word format)

File Download Opens in a new window.Long-term care insurance nursing care/support required certification application (double-sided printing) (Word: 34KB)

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

File Download Opens in a new window.Questionnaire for preparing the attending physician's opinion (Word: 37KB)

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.Application for Nursing Care Insurance Burden Limit Approval (PDF: 157KB)

File Download Opens in a new window.Special address application/change/termination notification form (PDF: 160KB)

File Download Opens in a new window.[For individuals] Personal information disclosure request form (PDF: 299KB)

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.Power of attorney for nursing care insurance related procedures (PDF: 132KB)

Other formats (Word/Excel format)

File Download Opens in a new window.Application form for (re)issuance of long-term care insurance insurance card, etc. (Excel: 31KB)

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

File Download Opens in a new window.Special address application/change/termination 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 regarding nursing care insurance related procedures (Word: 13KB)

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Inquiries regarding this page

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

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Elderly Welfare Division

  • Nursing care insurance related

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Inagi City official character Inagi Shinanosuke

Inagi City Hall

2111 Higashi-Naganuma, Inagi-shi, Tokyo 206-8601
Office hours: 8:30 a.m. to 5:00 p.m. Main phone: 042-378-2111 Fax: 042-377-4781
Copyright (C) Inagi City. All rights reserved.
Copyright （C）K.Okawara・Jet Inoue. All rights reserved.
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