How much does the referral surcharge actually cost?

The minimum additional fee for arriving without a referral at a hospital with 200+ beds is set by MHLW and was ¥7,000 (excluding tax) at the 2024 revision. Designated advanced medical institutions (including university hospitals) have higher minimum surcharges — ¥11,000 or more. The hospital sets the actual amount above the minimum, and it is not covered by insurance.

Can I get a referral letter from any doctor?

Yes. Any licensed physician who has examined and documented your condition can write a referral letter. In practice, your clinic physician writes the letter when they have assessed your condition and concluded that specialist or hospital-level care is appropriate. The letter is addressed to the specific hospital or specialty you are being referred to.

Is the referral letter required to be in Japanese?

The standard referral letter (診療情報提供書, shinryō jōhō teikyōsho) is a standardized Japanese-language form. The receiving hospital's staff will read it; you do not need to read it yourself. If your clinic produces an English summary as an additional document, that can be helpful context for international patient departments but does not replace the standard form.

What is a return referral (gyaku shōkai)?

When hospital specialist care is no longer actively needed but ongoing monitoring is appropriate, the hospital sends a return referral (逆紹介, gyaku shōkai) back to your local clinic. This transfers ongoing management back to the clinic, reducing hospital outpatient congestion. Continuing to visit the hospital for routine monitoring after receiving a gyaku shōkai may result in additional charges.

System Basics

Referral Letters and the Selected-Hospital Fee

How referral letters (shōkaijō) work in Japan's healthcare system, when you need one, how to request it, and what the selected-hospital fee costs if you skip it.

Who this is for

Foreign residents moving from a clinic to a hospital or specialist for the first time, or anyone who wants to avoid the surcharge for arriving at a large hospital without a referral.

Why referral letters exist in Japan

Japan’s healthcare design aims to reserve large hospitals and specialist centers for patients who genuinely need that level of care, while reserving clinics for primary and routine medical needs. The referral letter system (紹介状, shōkaijō) is the mechanism that enforces this pathway.

When a clinic physician has assessed your condition and determined that specialist consultation, advanced imaging, inpatient care, or surgical intervention is needed, they issue a referral letter addressed to the appropriate specialist or hospital department. The letter contains your diagnosis, relevant test results, treatment history, current medications, and the reason for referral — a standardized summary (診療情報提供書, shinryō jōhō teikyōsho) that the receiving physician reads before seeing you.

The financial incentive to use the referral pathway

If you arrive at a large hospital’s outpatient department for a first visit without a referral letter, you will be asked to pay a surcharge — formally called the selected-hospital fee (選定療養費, sentei ryōyōhi) or special additional charge (特別料金, tokubetsu ryōkin). This charge is separate from and in addition to your standard 30% insurance copayment. It is not covered by any insurance scheme.

MHLW sets minimum thresholds for these surcharges based on the size and designation of the hospital. For 2024, hospitals with 200 or more beds must charge at least ¥7,000 for a first visit without a referral. Designated advanced medical institutions (特定機能病院) — which include university hospitals and other highly specialized tertiary care centers — must charge at least ¥11,000. Individual institutions may set higher amounts above these minima.

The practical implication: going to a large hospital or university hospital without going through a clinic first costs substantially more. Starting at a clinic, getting a referral, and then attending the hospital generally costs less overall even accounting for the clinic visit fee.

How to request a referral letter

If you have been attending a clinic for a condition and believe you need specialist input or hospital investigation, discuss this with your clinic physician. In most cases, the physician will initiate the referral when they judge it clinically appropriate.

If you have a specific hospital in mind (for example, a hospital with English-speaking staff or an international patient center), you can mention your preference to your clinic physician. Referral letters can typically be addressed to a specific hospital department or, for more flexibility, to a type of specialist without specifying the institution.

The letter is usually ready on the same day or within a few business days of the clinic visit when the physician agrees a referral is appropriate. It is a sealed document — you carry it to the hospital and hand it in at the reception desk.

After the referral: the return pathway

When your hospital treatment is complete, or when your condition has stabilized to the point where specialist hospital monitoring is no longer necessary, the hospital physician may issue a return referral (逆紹介, gyaku shōkai) back to your primary care clinic. This document summarizes what was done at the hospital, any ongoing treatments or medications, and what follow-up the clinic should provide.

If you continue attending the hospital’s outpatient department after a return referral has been issued and there is no current clinical need for hospital-level care, the hospital may apply additional charges for continued attendance beyond the referral pathway’s design.

Last reviewed: September 2026

Key terms

English	Japanese	Romaji
Referral letter	紹介状	shōkaijō
Selected-hospital fee / surcharge	選定療養費（特別料金）	sentei ryōyōhi / tokubetsu ryōkin
Designated advanced medical institution	特定機能病院	tokutei kinō byōin
Return referral	逆紹介	gyaku shōkai
Medical summary	診療情報提供書	shinryō jōhō teikyōsho
Outpatient department	外来	gairai
First visit	初診	shoshin
Follow-up visit	再診	saishin

Common questions

How much does the referral surcharge actually cost?: The minimum additional fee for arriving without a referral at a hospital with 200+ beds is set by MHLW and was ¥7,000 (excluding tax) at the 2024 revision. Designated advanced medical institutions (including university hospitals) have higher minimum surcharges — ¥11,000 or more. The hospital sets the actual amount above the minimum, and it is not covered by insurance.
Can I get a referral letter from any doctor?: Yes. Any licensed physician who has examined and documented your condition can write a referral letter. In practice, your clinic physician writes the letter when they have assessed your condition and concluded that specialist or hospital-level care is appropriate. The letter is addressed to the specific hospital or specialty you are being referred to.
Is the referral letter required to be in Japanese?: The standard referral letter (診療情報提供書, shinryō jōhō teikyōsho) is a standardized Japanese-language form. The receiving hospital's staff will read it; you do not need to read it yourself. If your clinic produces an English summary as an additional document, that can be helpful context for international patient departments but does not replace the standard form.
What is a return referral (gyaku shōkai)?: When hospital specialist care is no longer actively needed but ongoing monitoring is appropriate, the hospital sends a return referral (逆紹介, gyaku shōkai) back to your local clinic. This transfers ongoing management back to the clinic, reducing hospital outpatient congestion. Continuing to visit the hospital for routine monitoring after receiving a gyaku shōkai may result in additional charges.

Sources