費用支払い申請書

Fee payment request and receipt form for consultation or certification services.

Form type: fee
Language: Japanese (日本語)
Archive source: AMDA-IMIC Japan forms library, 2013–2024

About This Form

This page documents the 費用支払い申請書 as provided in Japanese through AMDA-IMIC's multilingual forms library. The form is used for: fee payment request and receipt form for consultation or certification services..

Medical fee transactions in Japan involve a standardized receipt and payment documentation trail, especially when costs are later submitted to insurers or reimbursed by employers. AMDA-IMIC's fee payment form was used for services where the center itself charged a nominal fee — such as interpreter coordination or document certification assistance — as well as to document fees the patient paid to third-party providers as part of a consultation organized through the center.

For the original administrative forms in active use, contact the relevant Japanese institution directly — a hospital, employer, local health center, or labor bureau — depending on which form is needed. This reference documents the structure and purpose of the forms as they were used during the 2013–2024 period when AMDA-IMIC was operating.

Form Sections and Fields

The following sections and fields appear in the Japanese version of this form. Field labels are rendered here in English for reference; the original form presents them in Japanese (日本語).

Service date
Service type (consultation coordination / certification / interpretation / documentation)
Patient or client full name
Patient date of birth
Fee amount in Japanese yen (JPY)
Fee breakdown (service fee / documentation fee / interpreter fee / other)
Payment method (cash / bank transfer / insurance direct billing)
Receipt number
Issuing institution name and contact
Authorized officer name and signature
Institution seal

How to Obtain This Form

The forms documented on this site were originally distributed by AMDA-IMIC through its consultation service and language-specific subdomains. Since the center closed in 2024, the forms are no longer distributed through that channel. Equivalent forms for current use are available from the relevant Japanese institution: municipal health centers issue administrative forms, hospitals provide their own registration and appointment materials, and the Labor Standards Inspection Office supplies labor insurance documentation.