• Independence Support Medical Expenses (Mental Outpatient Medical Care) Supply Certification Application Form

* Please fill in by the applicant himself (or guardian if under 18 years old).

• medical certificate "Self-reliance support medical certificate (mental hospital)"

*Must be within 3 months from the date listed by the attending physician of the designated medical institution.
*Medical certificate fees are not covered by medical expenses for independence support.
*In some cases, you may not need to attach a medical certificate.
* For those who do not fall under "severe and continuous", a "medical certificate" written by a doctor at a designated medical institution
You have a "Mental Health Welfare Handbook" issued based on "New" or "Restart"
when applying. ⇒ However, a copy of the notebook is required.
*If you apply for renewal within the valid period, and if you applied with the previous "medical certificate" attached.
★ For more information, community health center or Welfare Division for Persons with Disabilities Please contact us.

• Copy of health insurance card (Excluding those receiving public assistance)

○“Social insurance/individual”…Insurance card for the individual is required.
○“Social Insurance/Family”: Health insurance cards of both the patient and the insured person are required.
However, if the insured person can be identified by the patient's health insurance card,
This is possible only with the patient's insurance card.
○ “National Health Insurance” … National Health Insurance Cards for all households enrolled in the same National Health Insurance
Is required. The same applies to the National Health Insurance Society.
*If you have an “Elderly Recipient Certificate”, please bring it with you.
○Late-stage elderly (longevity) medical care system: for all households subscribing to the latter-stage elderly (longevity) medical care system
"Late-stage elderly medical insurance card" is required.

• About the Individual Number (My Number) System

From November 13, 2017, information sharing using personal numbers (my numbers) will be implemented between local governments.
Full-scale operation has started.
Along with this, some of the documents required at the time of application can now be omitted.

Please bring the following documents when applying.
○ Documents that show your personal number (my number) (one of the following three)
□Notification card
□ Personal number (my number) card
□ A copy of your resident card with your Individual Number (My Number) or a certificate of registered items in your resident card, etc.
*Depending on your health insurance, you may also need your family's Individual Number (My Number).
○ Documents to confirm the applicant's identity
□ Mental Disability Health and Welfare Notebook (with photo), public certificate with photo such as driver's license
*If you do not have an official photo ID, please contact the Health Center in advance.

★Documents that can be omitted
○ Municipal tax taxation (tax exemption) certificate… If you have not filed your municipal tax yet, you must do so in advance.
・In cases where resident tax is levied in Shinjuku Ward, we will check it using public records.
Please sign your consent in the designated column of the application form to confirm the information held by Shinjuku City.
・In cases where resident tax is not levied in Shinjuku Ward, an individual number (My Number) is used.
Information will be confirmed by linking information, so please enter the information held by Shinjuku City, etc. in the designated column of the application form.
Please sign consent to confirm.
○ Public assistance receipt certificate (for those receiving public assistance)
○ Standard burden amount reduction certificate (households where all members of the household on the resident card are exempt from taxation)
*In some cases, information linkage using an individual number (my number) may occur on the day of application.
Since the inquiry is not completed, the application documents may be put on hold.
Also, please note that there may be cases where the above documents cannot be omitted.
★ For more information, community health center or Welfare Division for Persons with Disabilities Please contact us.

• Recipient certificate original (for renewal)

* For medical examinations until a new recipient certificate is issued, it will be handed over at the time of application.
Please present a copy of the recipient's certificate and a copy of the application form to the medical institution.

• Those who are covered by National Health Insurance in Tokyo

Shinjuku City National Health Insurance will cover the copayment, so in principle, there will be no copayment.
Submission of National Health Insurance recipient certificate issuance application form is required.
* Union National Health Insurance and National Health Insurance of municipalities outside of Tokyo are not covered, so please contact the National Health Insurance Association or the section in charge of National Health Insurance for the amount of copayment.

• Social insurance, Those who are enrolled in the medical system for the latter-stage elderly (longevity) and the National Health Insurance Association

Mental hospital outpatient medical expenses subsidy system in Tokyo there is.
If you apply, the Tokyo Metropolitan Government will subsidize the self-pay amount for independence support medical expenses. (In principle, there will be no copayment.)
It is necessary to fill in the specified column with a circle, so please let us know when you submit the application form.

Maximum burden amount for each income category

Welfare	Welfare household	[Upper limit of burden] 0 Yen
low income 1	In a ward tax exempt household Persons with a personal income of 800,000 yen or less (including public pension income, etc.)	[Upper limit of burden] 2,500 yen
low income 2	In a ward tax exempt household Individuals whose personal income exceeds 800,000 yen (including public pension income, etc.)	[Upper limit of burden] 5,000 yen
middle income 1	In households with a total of less than 33,000 yen for ward tax (income percent), Those who fall under high-cost treatment continuation (severe and continuation) * 1	[Upper limit of burden] 5,000 yen
middle income 2	For households with a total of 33,000 yen to less than 235,000 yen for ward tax (income percent), Those who fall under high-cost treatment continuation (severe and continuation) * 1	[Upper limit of burden] 10,000 yen
Above a certain income	For households with a total of 235,000 yen or more in ward tax (income percent), Those who fall under high-cost treatment continuation (severe and continuation) * 2	[Upper limit of burden] 20,000 Yen

*1 There is no maximum monthly burden for those who do not qualify as “severe and continuous”.
Self-payment will be up to the self-payment limit of medical insurance.
*2 Those who do not qualify as “severe and continuous” cannot receive this system.

*The unit of “household” is not the family on the resident card, but the family covered by the same medical insurance.
"Same household" Family members enrolled in different medical insurances are considered separate households.
* "Household" income is classified according to the income of the insured person in the case of social insurance.

<Notice to people with income category “a certain income or higher”>
The independence support medical system based on the Act on Comprehensive Support for Persons with Disabilities is a transitional special measure. Until March 31, 2024 , Municipal inhabitant tax tax amount of 235,000 yen or more (above a certain income) and those who are continuing high-cost treatment (so-called severe and continuous) will also be extended.

Effective period is principle 1 year becomes.
In the case of a new/renewal application, the valid period will start on the day the application is received at the window, and will end on the last day of the previous month after one year.
Those who wish to renew must complete the renewal procedure. You can apply for renewal from 3 months before the expiration date of the validity period, so please proceed as soon as possible. In addition, if the renewal application is approved, the new expiration date will be one year after the expiration date of the current recipient's certificate.

where you live community health center Or we accept in person with a disability welfare section.
・ Ushigome Health Center 6 Yarai-cho, Shinjuku-ku Phone: 03-3260-6231
・ Yotsuya Health Center 10-16 Yotsuya Sanei-cho, Shinjuku-ku Phone: 03-3351-5161
・ Higashi-Shinjuku Health Center 7-26-4 Shinjuku, Shinjuku-ku Phone: 03-3200-1026
・ Ochiai Health Center 4-6-7 Shimoochiai, Shinjuku-ku Phone: 03-3952-7161
・ Welfare Division for Persons with Disabilities  Counselor Shinjuku Ward Office Main Building 2F Phone: 03-5273-4518

* If the application is received by the Welfare Division for Persons with Disabilities or a health center not in charge, it will be submitted to the Tokyo Metropolitan Government via the health center in charge, so it may take longer than usual to receive approval.

If approved, the Tokyo Metropolitan Government will issue a recipient certificate to the Health Center about two to three months after the date of application, and the Health Center will send it to the applicant's home.

【change】
If the contents of the recipient's certificate are to be changed, it is necessary to apply for a change using the "notification of change of registered items". "Notification of Change of Information" health center・ Welfare Division for Persons with Disabilities Please bring your beneficiary certificate and a document confirming the reason for the change to the reception desk and follow the procedures.

[Reissue]
If you lose, damage, or deface your recipient's identification card, please apply for reissuance using the "reissuance application form." , "reissuance application form" health center・ Welfare Division for Persons with Disabilities is in
(In the case of damage or defacement, please attach your current recipient identification card.)