Documents Necessary for Statutory benefits｜Private School Mutual Aid online

Some forms can be downloaded from this website.

Note:
Forms and documents for submission may change. Contact the school office or PMAC for confirmation.

Health care benefits
Leave benefits
Disaster relief benefits

Health care benefits

Medical Treatment Benefit, Meal costs during hospitalization, Living costs during hospitalization, Parallel Uninsured Medical Coverage, Home-visit nursing care benefit, Dependent’s home-visit nursing care benefit

Documents required	Present the Membership Card or Membership Card for a Dependent at the medical institution.
Note	< No procedures are required >

Copayment refund, Copayment refund for dependent

Note:
1. When you had medical treatment without showing insurance card
2. When you had medical treatment overseas

Documents required	★Claim form for ”Copayment refund, Copayment refund for dependent” < Visits using other insurances > ◇Original receipts used to clear up another insurance ◇Copy of statement of medical expenses issued by another insurance < Visits paid by yourself > ★Certificate for Receipt of Medical Treatment Fees or ◇Copy of statement of medical expenses ◇Original receipt < Visits outside of Japan > ★ Attending Physicians’ statement ★ Record of medical care overseas ★ Agreement of Authorization ◇Original receipt ◇ Documents to certify your passage Documents in foreign language requires a Japanese translation < Creating Orthotics > ◇Original written opinion of the doctor ◇Original receipt (full statement)
Note	For other causes of claim refer to ”Submit appropriate forms and documents as follows”. < Need to apply >

Documents required

★Claim form for ”Copayment refund, Copayment refund for dependent”

< Visits using other insurances >
◇Original receipts used to clear up another insurance
◇Copy of statement of medical expenses issued by another insurance

< Visits paid by yourself >
★Certificate for Receipt of Medical Treatment Fees or
◇Copy of statement of medical expenses
◇Original receipt

< Visits outside of Japan >
★ Attending Physicians’ statement
★ Record of medical care overseas
★ Agreement of Authorization
◇Original receipt
◇ Documents to certify your passage
Documents in foreign language requires a Japanese translation

< Creating Orthotics >
◇Original written opinion of the doctor
◇Original receipt (full statement)

Note

For other causes of claim refer to ”Submit appropriate forms and documents as follows”.
< Need to apply >

Benefit for High-cost Medical Care

Documents required	When the Membership Card is presented at the hospital, no other procedures are required. ★Submit the ”Claim form for medical treatment expenses” when a member or dependent paid in full. < Need to apply >
Note	You must apply in advance when you wish to reduce the copayment of High-cost Medical Care for hospitalization. ★Submit the “Claim form for Maximum Amount Application Certificate“.

Benefit for Combined High-cost Medical Care

Documents required	◇“Claim form for Benefit for Combined High-cost Medical Care and Issuance of Copayment Certificate” ◇Copayment Certificate
Note	< Need to apply >

Transportation expense benefit for member or dependent

Documents required	★ “Claim form for Transportation expense benefit for member or dependent” ◇Transportation receipts
Note	< Need to apply >

Maternity Benefit, Dependent Maternity Benefit

Documents required	“Claim form for Maternity Benefit”
Note	When the Direct Payment System after childbirth is used, no procedures are required. < Need to apply >

Burial Benefit, Dependent Burial Benefit

Documents required	★“Claim form for Burial Benefit” ◇Original copy of “Family Register” from which the name of the deceased has been removed, original copy of Death Certificate, or copy of Cremation Permit
Note	If a member without any dependents dies, attach the original receipt and full statement for the burial expense which is addressed to the claimant. The cause of death must be specified in detail < Need to apply >

Documents required

★“Claim form for Burial Benefit”
◇Original copy of “Family Register” from which the name of the deceased has been removed, original copy of Death Certificate, or copy of Cremation Permit

Note

If a member without any dependents dies, attach the original receipt and full statement for the burial expense which is addressed to the claimant.
The cause of death must be specified in detail

< Need to apply >

Leave benefits

Sickness and Injury Allowance

Documents required	★”Claim form for Sickness and Injury Allowance”
Note	Claim shall be filed on a monthly basis. Each claim of the month is accepted from the following month onwards. < Need to apply >

Maternity Allowance

Documents required	★”Claim form for Maternity Allowance”
Note	The Maternity Allowance is payable as one off payment (by claiming after 56 days of childbirth) or in two installments (one installment before birth and the other after childbirth) < Need to apply >

Leave Allowance

Documents required	★”Claim form for Leave Allowance”
Note	Written evidence of leave of absence from work is also required. < Need to apply >

Disaster relief benefits

Condolence Benefit, Dependent Condolence Benefit

Documents required	★ ”Claim form for Member’s/Dependent’s Condolence Benefit” ◇Situation Report
Note	Original copy of “Family Register” is required to prove that the claimer is a bereaved family. < Need to apply >

Disaster Relief Benefit

Documents required	◇“Claim form for Disaster Relief Benefit” ◇”Disaster Situation Report”
Note	The disaster situation and damage must be described in detail in the “Disaster Situation Report”. < Need to apply >