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.
Click here for the form for businesses
Long-term care/support certification application (PDF format)
Long-term care insurance long-term care, support required certification application (both sides printing) (PDF: 495KB)
(entry example) long-term care insurance long-term care, support required certification application (PDF: 684KB)
Long-term care insurance (certification of need for long-term care and support) cancellation application (PDF: 76KB)
Questionnaire (PDF: 275KB) for chief physician written statement of opinion making
Application for long-term care/support certification (word format)
Long-term care insurance long-term care, support required certification application (both sides printing) (Word: 34KB)
Long-term care insurance (certification of need for long-term care/support) cancellation application form (Word: 20KB)
Questionnaire (Word: 37KB) for chief physician written statement of opinion making
Other forms (PDF format)
Application for reissue of nursing care insurance certificate, etc. (PDF: 296KB)
Long-term care insurance burden limit authorization application (PDF: 157KB)
Address ground exception application, change, end notification form (PDF: 160KB)
[For individuals] Personal information disclosure request form (PDF: 300KB)
Notification of destination setting for nursing care insurance-related documents (PDF: 97KB)
Proxy (PDF: 132KB) about care insurance-related procedure
Other forms (Word/Excel format)
Identification of long-term care insurance person insured (re) grant application (Excel: 31KB)
Long-term care insurance burden limit authorization application (Excel: 67KB)
Address ground exception application, change, end notification form (Excel: 35KB)
[For individuals] Personal information disclosure request form (Excel: 18KB)
Notification of destination setting for nursing care insurance-related documents (Excel: 42KB)
Power of attorney (Word: 13KB) about care insurance-related procedure
Inquiries about this page
Elderly Welfare Division, Welfare Department, Inagi City Telephone: 042-378-2111