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Medical care for the elderly in later stages of life

Updated: November 27, 2024

It is in PDF file format, so please print it out and use it.
Note: If the following documents 2, 3, and 14 are brought to the counter by someone other than the applicant, please bring something that can be used to verify the identity of the person bringing the application form.

File Download Opens in a new window.1 Notification of acquisition (change/loss) of medically insured qualification for the elderly (PDF: 86KB)

File Download Opens in a new window.2 Application and petition for medical care and funeral expenses for the elderly (PDF: 73KB)

File Download Opens in a new window.3 Notification of designation of heir representative regarding medical care for the elderly (PDF: 77KB)

File Download Opens in a new window.4. Confirmation of the designation of representative of heirs (PDF: 340KB)

File Download Opens in a new window.5. Application for reissuance of medical insurance for the elderly (PDF: 67KB)

File Download Opens in a new window.6 Application for issuance of certificate of medical eligibility for the elderly and for inclusion of optional information (PDF: 104KB)

File Download Opens in a new window.7. Application for reduction or exemption of medical insurance premiums for the elderly (PDF: 75 KB)

File Download Opens in a new window.8 Application for certification of specific diseases for medical treatment for the elderly (PDF: 79 KB)

File Download Opens in a new window.9 Doctor's (dentist's) opinion for certification of specific diseases for medical treatment of the elderly (PDF: 94KB)

File Download Opens in a new window.10 Application for suspension of special collection of medical insurance premiums for the elderly (PDF: 85 KB)

File Download Opens in a new window.11 Application for resumption of special collection of medical insurance premiums for the elderly (PDF: 79 KB)

File Download Opens in a new window.12 Application for Certificate of Medical Care Costs for the Elderly (PDF: 73 KB)

File Download Opens in a new window.13 Request for change of delivery address for mailings related to medical care for the elderly (PDF: 72KB)

File Download Opens in a new window.14 Application form for canceling registration of My Number Card as a health insurance card (PDF: 222KB)

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

To open PDF files, you need Adobe Acrobat Reader DC (formerly Adobe Reader).
If you don't have it, you can download it for free from Adobe.
Get Adobe Acrobat Reader DCDownload Adobe Acrobat Reader DC

Inquiries about this page

Inagi City Citizens Department Insurance and Pension Division
2111 Higashi-Naganuma, Inagi-shi, Tokyo
Phone: 042-378-2111 Fax: 042-377-4781

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Insurance and Pension Division

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Inagi City Hall

2111 Higashinagumanuma, Inagi City, Tokyo 206-8601
Office hours: 8:30 a.m. to 5:00 p.m. Main phone: 042-378-2111 Fax: 042-377-4781
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