1 Application form of medical benefits for patients with specified diseases

1. First Time Application for Medical Benefits for Patients with Specified Disease If you have enrolled in the “national health insurance (provided by your local community)” and below the age of 70 You will become eligible for the medical benefits on the day you submit documents necessary for application to the health center. Submit the documents specified below to your local health center as soon as possible. *The medical benefits for patients with specified diseases is a system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare under personal information protection (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information of the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the “Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) of the eligible to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through a screening before receiving the beneficiary certificate. Note that not all applicants can receive medical benefits. Documents Necessary for Application (Please bring your seal) 1 Application form of medical benefits for patients with specified diseases 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date *An X-ray picture or other resources may be required depending on the disease 3 Documents confirming the final income tax or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure,severe pancreatitis or severe erythema multiformedoes not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural tax: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension (postcard-size document mailed around January) 4 Residence certificate of all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare documents 6 and 7.] 6 Consent form *The local community is allowed to tell the income group of person insured to the prefectural government as stipulated by your local community code based on the “Act on the Protection of Personal Information” or other applicable laws. Handling of personal information is based on the local or other codes. Whether to request the consent depends on each local community. For more information, contact your local public health center. 7 Copy of “Amount Limit Certificate” or “Amount Limit and Standard Self-Pay Reduction Amount Certificate” (if any)

2. First Time Application for Medical Benefits for Patients with specified Disease If you have enrolled in the “national health insurance (provided by your local community)” and aged 70 or over You become eligible for medical benefits on the day when you submit documents necessary for application to the public health center. Submit the documents specified below to your local public health center as soon as possible. *The medical benefits for patients with specified diseases is the system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare under personal information protection (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information on the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the "Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) about the eligible person to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through the eligibility screening before receiving the beneficiary certificate. Note that not all applicants can receive the medical benefits. Documents Necessary for Application (Please bring your seal) 1 Medical benefits for patients with specified diseases application form 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date. *An X-ray picture or other materials may be required depending on the disease. 3 Document for confirming the income or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme does not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural taxes: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension (postcard-size document mailed around January) 4 Residence certificate for all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare documents 6 through 8.] 6 Consent form *The local community is allowed to tell the income group of person insured to the prefectural government as stipulated by your local community code based on the “Act on the Protection of Personal Information” or other applicable laws. Handling of personal information is based on the local or other codes. Whether to request the consent depends on each local community. For more information, contact your local public health center. 7 Copy of “amount limit and standard self-pay amount reduction certificate” (if any) 8 Copy of elderly beneficiary certification (30% self-pay)if you are recognized as an active worker in terms of income *One of persons insured aged 70 or over in the family has a taxable income of 1.45 million or more, you are recognized as an active worker in terms of income.

3. First Time Application for Medical Benefits for Patients with specified Disease If you have enrolled in the “Advanced older age medical care program” You become eligible for medical benefits on the day when you submit documents necessary for application to the public health center. Submit the documents specified below to your local public health center as soon as possible. *The medical benefits for patients with specified diseases is the system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare under personal information protection (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information on the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the "Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) about the eligible person to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through the eligibility screening before receiving the beneficiary certificate. Note that not all applicants can receive the medical benefits. Documents Necessary for Application (Please bring your seal) 1 Medical benefits for patients with specified diseases application form 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date. *An X-ray picture or other materials may be required depending on the disease. 3 Document for confirming the income or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme does not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural taxes: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension (postcard-size document mailed around January) 4 Residence certificate for all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare document 6.] 6 Copy of “amount limit and standard self-pay amount reduction certificate” (if any)

4. First Time Application for Medical Benefits for Patients with specified Disease If you have enrolled in a "national health insurance association" and below the age of 70 You become eligible for medical benefits on the day when you submit documents necessary for application to the public health center.Submit the documents specified below to your local public health center as soon as possible. *The medical benefits for patients with specified diseases is the system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare under personal information protection (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information on the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the "Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) about the eligible person to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through the eligibility screening before receiving the beneficiary certificate. Note that not all applicants can receive the medical benefits. Documents Necessary for Application (Please bring your seal) 1 Medical benefits for patients with specified diseases application form 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date. *An X-ray picture or other materials may be required depending on the disease. 3 Document for confirming the income or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme does not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural taxes: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension (postcard-size document mailed around January) 4 Residence certificate for all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare documents 6 through 8.] 6 Consent form *The national health insurance association is allowed to tell the income group of its member or person insured to the prefectural government as stipulated by the relevant rules and stipulations of the association based on the “Act on the Protection of Personal Information” or other applicable laws. Handling of personal information is subject to your consent based on the relevant rules and stipulations of your association. 7 “Income and taxation certificate” or “municipal inhabitant tax exemption certificate” of all persons who have enrolled in the same national health insurance association as the eligible person (copy permitted) 8 Copy of “amount limit certificate” or “amount limit and standard self-pay amount certificate” (if any) *7 is not required if you submit document 8.

5. First Time Application for Medical Benefits for Patients with specified Disease If you have enrolled in a "national health insurance association" and aged 70 or over You become eligible for medical benefits on the day when you submit documents necessary for application to the public health center. Submit the documents specified below to your local public health center as soon as possible. *The medical benefits for patients with specified diseases is the system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare under personal information protection (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information on the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the “Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) about the eligible person to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through the eligibility screening before receiving the beneficiary certificate. Note that not all applicants can receive the medical benefits. Documents Necessary for Application (Please bring your seal) 1 Medical benefits for patients with specified diseases application form 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date. *An X-ray picture or other materials may be required depending on the disease. 3 Document for confirming the income or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme does not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural taxes: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension (postcard-size document mailed around January) 4 Residence certificate for all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare documents 6 through 10.] 6 Consent form *The national health insurance association is allowed to tell the income group of its member or person insured to the prefectural government as stipulated by the relevant rules and stipulations of the association based on the “Act on the Protection of Personal Information” or other applicable laws. Handling of personal information is subject to your consent based on the relevant rules and stipulations of your association. 7 “Income and taxation certificate” or “municipal inhabitant tax exemption certificate” of all persons who have enrolled in the same national health insurance association as the eligible person (copy permitted) 8 Copy of “amount limit and standard self-pay amount reduction certificate” (if any) *7 is not required if you submit document 8. 9 Copy of elderly beneficiary certification (30% self-pay) if you are recognized as an active worker in terms of income *7 is not required if you submit document 9. *One of persons insured aged 70 or over in the family has a taxable income of 1.45 million or more, you are recognized as an active worker in terms of income. 10 If you are categorized into the low-income I group, the “tax exemption certificate and statement of withholding for public pension or other applicable income” of the member as well as the “tax exemption certificate and statement of withholding for public pension or other applicable income” of the person insured (The person with serum hepatitis or hepatic cirrhosis does not need to prepare this document.) *The incomes of the member and the person insured are below a certain level, you are categorized into the low-income I group.

6. First Time Application for Medical Benefits for Patients with specified Disease If you have enrolled in the “employee’s health insurance (corporate health insurance, mariner insurance or mutual aid association)” and below the age of 70 The eligible person (patient) may not be necessarily the person insured. You become eligible for medical benefits on the day when you submit documents necessary for application to the public health center. Submit the documents specified below to your local public health center as soon as possible. *The medical benefits for patients with specified diseases is the system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information on the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the “Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) about the eligible person to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through the eligibility screening before receiving the beneficiary certificate. Note that not all applicants can receive the medical benefits. Documents Necessary for Application (Please bring your seal) 1 Medical benefits for patients with specified diseases application form 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date. *An X-ray picture or other materials may be required depending on the disease. 3 Document for confirming the income or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme does not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural taxes: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension(postcard-size document mailed around January) 4 Residence certificate for all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare documents 6 through 8.] 6 Consent form *The insurer is allowed to tell the income group of the person insured or nonworking dependent to the prefectural government as stipulated by the relevant rules and stipulations of the employee’s health insurance based on the “Act on the Protection of Personal Information” or other applicable laws. Handling of personal information is subject to your consent based on the relevant rules and stipulations of your employee’s health insurance. 7 Municipal inhabitant tax taxation (or exemption) certificate of the person insured (copy permitted) *If the person insured is the main earner in the family and not categorized in the low-income group (that is, the person is categorized in the standard or high-income group), the “taxation certificate of municipal inhabitant tax of person insured” is not required. (However, note that this document is required when applying for the certification for the patient with severe disease, SMON, prion disease, fulminant hepatic failure, or severe pancreatitis.) 8 Copy of “amount limit certificate” or “amount limit and standard self-pay amount reduction certificate” (if any) *7 is not required if you submit document 8. Income groups in context of medical insurance Standard group:You are recognized as an active worker in terms of income or not categorized in a low-income group. High-income group: The index monthly earnings of the person insured is 530,000 yen or higher. Low-income group: The person insured does not have to pay residential tax.

7. First Time Application for Medical Benefits for Patients with specified Disease If you have enrolled in the “employee’s health insurance (health insurance or mutual aid association)” and the person insured is aged 70 or over*The eligible person (patient) may not be necessary the person insured. You become eligible for medical benefits on the day when you submit documents necessary for application to the public health center. Submit the documents specified below to your local public health center as soon as possible. *The medical benefits for patients with specified diseases is the system intended to promote the study of severe and rare diseases. The applicant must agree that the submitted medical certificate (individual record of clinical survey) will be used as the basic data for disease study conducted as part of the scientific research in the Ministry of Health, Labor and Welfare under personal information protection (For details, refer to the opposite side of this paper). *The applicant must agree that we (Aichi prefectural government) can provide the information on the person who receives the medical benefits (called eligible person below) to the insurer or other relevant organization and obtain the income group information of eligible person from such organizations under the “Aichi Prefecture Personal Information Protection Code” so that we can provide the information (such as name and birth date) about the eligible person to these organizations and check his/her income group used for medical insurance or other purposes with these organizations. *This is the system intended to promote the study of severe and rare diseases. The applicant must go through the eligibility screening before receiving the beneficiary certificate. Note that not all applicants can receive the medical benefits. Documents Necessary for Application (Please bring your seal) 1 Medical benefits for patients with specified diseases application form 2 Medical certificate (individual record of clinical survey. Use the determined format.) *Submit the certificate written within three months before the application date. *An X-ray picture or other materials may be required depending on the disease. 3 Document for confirming the income or other details of the main earner in the family (copy permitted) (The patient with SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme. does not need to prepare this document.) (1) If you do not have to pay municipal inhabitant and prefectural taxes: Municipal inhabitant and prefectural tax exemption certificate *If you apply between April and June, submit the taxation certificate for the last fiscal year. If you apply between July and March, submit the taxation certificate for the current fiscal year. (2) If you pay the municipal inhabitant and prefectural taxes (If you have filed income tax returns, refer to (i). Otherwise, refer to (ii) or (iii).) *If you apply between January and June, submit the income tax certificate for the fiscal year before last. If you apply between July and December, submit the taxation certificate for the last fiscal year. (i) If you have filed income tax returns as self-employed worker or for medical expenses deduction or other purpose: Tax payment certificate (part 1) *1 If you cannot visit the tax office in person to receive the tax payment certificate, your authorized attorney who have a letter of attorney can perform the procedures. *2 If you have submitted the statement of withholding at the time of filing, submit the tax payment certificate (part 1) with the additional statement certifying the amount of taxes withheld. (ii) If you are a salaried worker (such as employee or public official): Statement of withholding (iii) If you do not receive any income other than the pension: Statement of withholding for public pension(postcard-size document mailed around January) 4 Residence certificate for all your family members (copy permitted) *Submit the certificate issued within three months before the application date. The head of household and relationship fields must be filled in. 5 Copy of your insurance card [The patient with serum hepatitis or hepatic cirrhosis does not need to prepare documents 6 through 10.] 6 Consent form *The insurer is allowed to tell the income group of the person insured or nonworking dependent to the prefectural government as stipulated by the relevant rules and stipulations of the employee’s health insurance based on the “Act on the Protection of Personal Information” or other applicable laws. Handling of personal information is subject to your consent based on the relevant rules and stipulations of your employee’s health insurance. 7 Municipal inhabitant tax taxation (or exemption) certificate of the person insured (copy permitted) *If the person insured is the main earner in the family and not categorized in the low-income group (that is, the person is categorized in the standard or high-income group), this document is not required. (However, note that this document is required when applying as the patient with severe disease, SMON, prion disease, fulminant hepatic failure, severe pancreatitis or severe erythema multiforme.) 8 Copy of “amount limit and standard self-pay amount reduction certificate” (if any) *7 is not required if you submit document 8. 9 Copy of elderly beneficiary certification (30% self-pay) if you are recognized as an active worker in terms of income　　*7 is not required if you submit document 9. 10 If you are categorized into the low-income I group, the “tax exemption certificate and statement of withholding for public pension or other applicable income” of the person insured as well as the “ tax exemption certificate and statement of withholding for public pension or other applicable income” of nonworking dependents Income groups in context of medical insurance Standard group: You are recognized as an active worker in terms of income or not categorized in a low-income group. The index monthly earnings of the person insured is 280,000 yen or higher, you are recognized as an active worker in terms of income. Low-income group II: The person insured does not have to pay residential tax. Low-income I group: The incomes of the person insured and nonworking dependents are below a certain level.

8. Medical Benefits for Patients with specified Diseases - These medical benefits are intended that Aichi Prefecture pays the self-pay medical expenses for the eligible person suffering from a specified disease to treat himself and to receive medical services provided under the Long-Term Care Insurance Act (home-visit nursing, home-visit rehabilitation, home care guidance, nursing facility service, preventative home-visit nursing, preventative home-visit rehabilitation and preventative home care guidance). The scope is limited to the expenses for medical treatment of the specified disease or other related services. Note that the treatment not covered by insurance is out of the scope. - If you pass the screening, the beneficiary certificate is issued to you. The “self-pay amount limit” at each medical facility for one month is printed on the beneficiary certificate for refund. Compare the specified amount with the amount of money you have paid, ask each medical or other facility to verify the insurance medical expenses on the “repayment request form”, fill in necessary items on it, and send it to the Specified Diseases Group, Health Policy Department, Aichi Prefecture by mail. The repayment money is transferred to your bank account at the last day of the month following the month when the form arrives. Please confirm repayment with your bank book. - When you receive the beneficiary certificate, check the name, address, and insurance card information (insurer number and symbol number). If the status changes, make an application to change the beneficiary certificate information within two weeks after the change. Be sure to bring the beneficiary certificate with you when making this application. Self-pay Amount - There might be some self-pay amount depending on the annual income tax of the main earner in the family. - The self-pay amount is as shown in the table below (as of April 1, 2011). - The main earner in the family is the person who mainly earns the living of the eligible person (such as the person insured of medical insurance). - The certified severe patient does not have to pay any money. A separate application is required to be certified as a severe patient. 1 month maximum limit of self-pay capping (for each medical facility) Bracket Admission Outpatient No municipal inhabitant taxation on the breader ○If the subject (patient) is the breader, the self-pay limit will be half the amount on the left Breader’s previous year income tax was tax free Breader’s previous year’s income tax levy was less than 5,000 yen ○If there are 2 subjects (patients) under the same living, the self-pay limit from the 2nd person onwards will be 1/10 the amount on the left Breader’s previous year’s income tax levy was from 5,001 ～ 15,000 yen Breader’s previous year’s income tax levy was from 15,001 ～ 40,000 yen (A broken number below 10 yen will be truncated) Breader’s previous year’s income tax levy was from 40,001 ～ 70,000 yen Breader’s previous year’s income tax levy was more than70,001 yen * You do not have to pay for insurance dispensing at a drug store according to external prescription and home-visit nursing regardless of your group category. [Code lists] 1. Relationship with the eligible person 01 Self 02 Father 03 Mother 04 Husband 05 Wife 06 Eldest Son 07 Eldest Daughter 08 Second Son and Below 09 Second Daughter and Below 10 Brother 11 Little Brother 12 Sister 13 Little Sister 14 Others 2. Occupation 01 Agriculture 02 Forestry, Hunting 03 Fishery, Aquaculture 04 Mining 05 Construction 06 Manufacture 07 Retailing 08 Finance, Insurance 09 Real Estate Industry 10 Transport, Communication Industry 11 Electricity, Gas, Water Provider 12 Service Business 13 Liberal Profession 14 Student 15 Not Working 16 Others Agreement regarding the Medical Certificate (medical checkup card) being used for research Medical Benefit for Patients with specified Diseases is a system which the patient’s medical fees will be partially aided by government expenses, in order to facilitate the research of the severe and rare specified disease. The medical checkup card, attached to the application, will be used as a basic data by the Ministry of Health, Labor and Wealth fare; the Health and Labor Sciences Overcoming Intractable Disease for specified Disease Research Group. After agreeing to the terms, please get the grant application for the medical benefit for patients with specified diseases recipient. Also, regarding the usage of the medical checkup card, based on the law of protecting personal information, it will not be used other than the purpose of the research. In addition, this is an agreement against the usage of the medical checkup card as a basic data for the research for disease. If there is a time where the specified disease research group needs the patient’s cooperation regarding a clinical research, the researchers will once again get on contact with the patient’s family doctor to explanations regarding the research, to get proper authorization from the patient. About the disease for serum hepatitis and hepatic cirrhosis, agreement is not necessary for those are diseases which the Aichi prefecture operates the medical benefit on one’s own accord.