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※入力は日本語でお願いします。(Input in Japanese, please.)

お問い合わせ項目
(Inquiry items)Required





お問い合わせ内容
(Content of inquiry)Required
氏名
(Full name)Required
保険証の記号
(Health insurance card code)Optional
保険証の番号
(Health insurance card number)Optional
メールアドレス
(Email address)Required

確認のため再度ご入力下さい。(Please write again for confirmation.)

電話番号
(Phone number)Optional

Application for notification of medical expenses for final tax return (Dependents will also be issued)

Please check PepUp for information on regular medical expenses.
※入力は日本語でお願いします。(Input in Japanese, please.)

保険証の記号
(Health insurance card code)Required
保険証の番号
(Health insurance card number)Required
生年月日
(Birth date)Required
氏名
(Full name)Required
住所
(Address)Required
メールアドレス
(Email address)Required

確認のため再度ご入力下さい。(Please write again for confirmation.)

発行して欲しい年
("Year" that you want to issue) Required

The card can be issued from 2017
Prior to that, it will not be issued because it cannot be used in final tax returns.

備考
(Additional notes)Optional