Application forms | Procedures | Novartis Health Insurance Association

Health insurance eligibility and application-related forms

Form	Example	How to submit
Notification of Health Insurance Dependent (Change) Notification of Health Insurance Dependent (Change)	Example	※A
A claim for the National Pension no.3 insured person	Example	※A
Report on Circumstances of Dependent(spouse)	―	※A
Report on Circumstances of Dependent(except spouse and child)	―	※A
Application Form for Reissue of Health Insurance Card	―	※B
Notification of Health Insurance Card Loss	―	※B
Notification of Health Insurance Name Change of Insured Person	Example	※A
Application Form for Certification as Health Insurance Voluntarily and Continuously Insured Person	Example	※C
A Confirmation Letter of Health Insurance Voluntarily and Continuously Insured Person	―	※C
Application Form for disqualification as Health Insurance Voluntarily and Continuously Insured Person	Example	※C
Notification of Change of Registration Matters for a Voluntarily and Continuously Insured Person	―	※C
Notification of Long-term Care Insurance (Qualification/ Disqualification)	―	※B

Form	Example	How to submit
Application Form for Medical Care Expenses for insured person and dependent	Example	※C
Application Form for Medical Care Expenses for insured person and dependent(overseas)	Example	※C
A letter stating that you agree to the health insurance society making detailed inquiries to the overseas medical care institution or other organization about your treatment	Example	※C
Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum	Example	※C
Claim for Maternity Allowance	Example	※A
Claim for Injury and Sickness Allowance/ Additional Sum	Example	※B
Claim for Funeral Expenses/ Additional Sum	Example	※C
Notification of Injury or Sickness due to a Third-party Act	―	※C
Written pledge (declaration of consent)	―	※C
Car insurance contract status report	―	※C
Request for issuance of Maximum Co-payment Certificate for Health Insurance	―	※C

Form	Example	How to submit
Application Form for a subsidy of gynecological cancer screening	―	※C
Application Form for a subsidy of dental treatment	―	※C