Key Takeaways
- "Referral letter" (shokaijo) is the everyday name; in insurance-covered care the document attached to a referral is the medical information letter (shinryo joho teikyosho), prepared on Attached Form 11 of the implementation notice or an equivalent format.
- The medical information provision fee (I) (B009) is 250 points, billed once a month per patient per receiving institution when, based on care, the physician finds care at another institution necessary and refers the patient with the patient's consent and a document describing the clinical situation.
- Onjishi is the honorific prefix 'o' added to jishi, a term written beside the addressee's name to show respect, and dictionaries note that it is widely used in the medical field.
- Under the FY2026 revision, the physician's signature or name and seal on a medical information letter may be omitted from the second time onward, or when it is clear the letter came from the issuing institution, such as when handed over directly.
"Should the addressee line say onjishi or okika?" "How do I address it when I don't know the physician's name?" "How many points can we bill for a referral letter?" These questions come up again and again from physicians who write referral letters at clinics and from medical office staff who prepare the envelopes and copies. Based on the medical fee schedule (FY2026 MHLW public notice), the implementation notice, related laws and dictionary entries, this article explains how to write a referral letter (medical information letter) and how to address it and its envelope.
Disclaimer: This article is general information based on publicly available information as of October 31, 2026. The MHLW public notices and notifications are the authoritative source for points, requirements and forms. Always confirm the latest original text and the handling of your regional bureau of health and welfare and review body before making billing decisions. How to address letters and envelopes is not set by law; the examples here reflect common custom.
What is a referral letter? Its relationship to the medical information letter
A referral letter (shokaijo) is the everyday name for the document a physician writes to convey the patient's clinical situation when referring the patient to another institution. In insurance-covered care, the document attached to a referral is called a medical information letter (shinryo joho teikyosho), and the MHLW implementation notice provides forms for it (such as Attached Form 11).
Referrals have a legal basis.
| Source | Content |
|---|---|
| Medical Care Act, Article 1-4(3) | Physicians working at medical facilities must endeavor, for the division of functions and cooperation among facilities, to refer patients to other facilities as needed, provide clinical information to the extent necessary for care, and take other necessary measures |
| Rules on Medical Care under Health Insurance, Article 16 | When a patient's condition is outside the physician's specialty, or there is doubt about the care, the insurance physician must take appropriate measures such as transferring the patient to another insurance medical institution or seeking a consultation with another insurance physician |
| Same rules, Article 16-2 | When another insurance medical institution or physician makes an inquiry about a patient the physician treated, the physician must respond appropriately |
Without a referral letter, the patient may pay more
When a patient visits an advanced treatment hospital, a regional medical support hospital with 200 or more general beds, or a referral-focused medical institution with 200 or more general beds without a referral letter, a special charge applies on top of the usual co-payment (7,000 yen or more for a first medical visit and 3,000 yen or more for a return visit). The MHLW FY2026 revision materials state that this fixed charge is "unchanged in this revision." A referral letter therefore also affects what the patient pays at the receiving institution.
Overview of the medical information provision fee (I) (B009)
When you write a referral letter and refer a patient, you bill the medical information provision fee (I) (category B009).
| Item | Content (public notice and implementation notice) |
|---|---|
| Points | 250 points |
| When it applies (Note 1) | When, based on care, the physician finds care at another insurance medical institution necessary and refers the patient with the patient's consent and a document describing the clinical situation |
| Frequency | Once a month per patient per receiving insurance medical institution |
| Prior coordination | Coordinate with the receiving institution before referring |
| Form | Fill in the form specified for each type of recipient, or an equivalent format, and give it to the patient or the receiving institution (for medical institutions, Attached Form 11 or Attached Form 11-2) |
| Keeping a copy | Attach a copy of the document to the medical record |
| Inquiries | Respond courteously to inquiries from the recipient about the patient |
| Examples not billable | Providing information to an institution with a special relationship; medical certificates for which the patient paid out of pocket; etc. |
Besides insurance medical institutions, the fee can apply to information provided to municipalities and home care support providers (Note 2, Attached Forms 12 to 12-4), long-term care health facilities and integrated care hospitals (Note 5, Attached Form 13), and school physicians at nursery schools and schools (Note 7, Attached Forms 14 to 14-3).
Main additions
| Addition | Points | Main situation |
|---|---|---|
| Dementia specialist referral addition (Note 10) | 100 | Referring a patient with suspected dementia to a specialist institution for differential diagnosis |
| Dementia specialist cooperation addition (Note 11) | 50 | Referring an outpatient already diagnosed with dementia by a specialist institution back to it when symptoms worsen |
| Psychiatrist cooperation addition (Note 12) | 200 | A non-psychiatric department refers an outpatient with suspected depression or other mental disorder after booking a psychiatric appointment |
| Hepatitis interferon treatment cooperation addition (Note 13) | 50 | Referring an outpatient with hepatitis needing long-term interferon therapy to a partner specialist institution |
| Dental cooperation addition 1 (Note 14) | 100 | Referring to a dental institution when oral function management is needed |
| Dental cooperation addition 2 (Note 15) | 100 | Referring to a dental institution after booking an appointment when perioperative oral function management is needed |
| Test and imaging information addition (Note 18) | 30 for outpatients | A notified institution provides test results, images and so on in an electronically viewable form, or attaches them to an electronically exchanged medical information letter |
Differences from similarly named fees
| Category | Points | Content |
|---|---|---|
| Medical information provision fee (II) (B010) | 500 | When a patient seeks another physician's opinion (a second opinion) and the institution supports it by giving the patient a document with the necessary information (once a month) |
| Enhanced cooperation information fee (B011) | 150 | When a document is provided at the request of, or under an agreement to jointly continue treatment with, the referring or receiving institution (facility standards apply; once every 3 months). Not billable in a month when fee (I) was billed for a referral to the same institution |
The form and its items (Attached Form 11)
Attached Form 11 (medical information letter) in the implementation notice has the following fields. Attached Form 11-2 has the same fields plus check boxes for the institution's notification status for the community comprehensive care addition, community comprehensive care fee, pediatric family doctor fee, comprehensive home care management fee and facility-resident comprehensive management fee.
| Field | What to write, with tips |
|---|---|
| Receiving institution and attending physician | Institution name, department, physician name (the form reads "Attending physician, Department of ___, dono") |
| Date | Date of writing |
| Referring institution's address, name and phone number | So the recipient knows where to inquire |
| Physician's signature (or name and seal) | See the FY2026 simplification below |
| Patient name, sex, date of birth, address, phone, occupation | If the recipient is not an insurance medical institution, always fill in address and phone |
| Diagnosis | Distinguish confirmed diagnoses from suspected ones |
| Purpose of referral | Be specific about what you want the recipient to do, such as "further examination and treatment" or "assessment of surgical indication" |
| Past and family history | Items relevant to treatment, including allergies |
| Course of symptoms and test results | Course since onset, key test values (with dates) |
| Course of treatment | Treatment given and its effect |
| Current prescriptions | Drug names, doses, directions |
| Remarks | What was explained to the patient, the patient's wishes, a request for a reply |
The notes on the form say to attach continuation sheets when needed and to attach imaging films and test records when needed. The cost of copying X-ray films and the like for the information is included in the fee and cannot be billed separately.
FY2026: simplified signatures and seals
The FY2026 revision reviewed signatures and seals on various forms to support medical DX and simplify work. For medical information letters, the physician's signature or name and seal may be omitted from the second time onward, or when it is clear the letter was sent by the issuing institution, such as when handed over directly (the notes on the form say that in this case only the physician's printed name is needed).
Addressing: onjishi, okika and sensei
What is onjishi? Meaning and reading
御侍史 (onjishi / gojishi) is one of the wakizuke, terms added beside the addressee's name to show respect.
- 侍史 (jishi): originally a secretary who handled documents beside a person of high rank. From this, it came to be used as a wakizuke written at the lower left of the addressee's name, meaning "presented through your secretary" (Seisenban Nihon Kokugo Daijiten; Digital Daijisen)
- 御侍史: Digital Daijisen describes it as having the same meaning as jishi and as a term widely used in the medical field
Because jishi already carries respect, some prefer jishi without the honorific "o". No official rule decides which is correct.
What is okika?
机下 (kika) is also a wakizuke, derived from "presenting it under your desk." Digital Daijisen notes that 御机下 (onkika / gokika) has the same meaning as kika and is commonly used in the medical industry.
How to choose
No law or official rule governs the choice between onjishi and okika. In practice, decide which to use in your clinic and keep it consistent.
| Example | When to use |
|---|---|
| [Hospital] [Department] Dr. [Name]-sensei Onjishi | When you know the attending physician's name |
| [Hospital] [Department] Attending Physician-sensei Onjishi | When you don't know the physician's name |
| [Hospital] [Department] Onchu | When addressing the department rather than an individual physician |
| Dr. [Name]-sensei Okika | When using okika |
The address field on the MHLW Attached Form 11 reads "Attending physician, Department of ___, dono." Using "dono" as on the form is fine; onjishi and okika are customary expressions.
How to write and seal the envelope
There is no legal rule for envelopes either. The following is a common example. Follow your clinic's format or the recipient's instructions if any.
Front
- In the center, the receiving institution, department, physician name and wakizuke (for example, "[Hospital] [Department] Dr. [Name]-sensei Onjishi")
- Writing "Medical information letter enclosed" or "Referral letter enclosed" at the lower left helps the recipient sort mail
- If mailing, the recipient's address at the upper right
Back
- The referring institution's name, address, phone number and physician name
- Date of writing
Sealing
- When the patient carries the letter, it is common to seal it. There is also a custom of writing "〆" on the seal
- If you enclose a CD-R of images or copies of test results, listing the contents in the remarks field makes them easier to check at the receiving end
Points to note when handing it to the patient
- Obtain consent: the medical information provision fee (I) requires explaining to the patient and referring with their consent
- Explain the destination and how to visit: whether an appointment is needed, what to bring (insurance card, medication handbook, image data, etc.) and roughly when to go
- Ask them not to open it: tell the patient to hand the sealed letter to the recipient unopened
- Keep a copy: attach a copy of the document given to the medical record (implementation notice)
- Track replies: being able to check in the clinic whether a reply has arrived from the recipient helps you follow the patient after referral
Cautions when drafting referral letters with AI
Systems that draft referral letters with generative AI from EMR records are spreading. Referral letters involve a lot of picking up diagnoses, course, test values and prescriptions from the chart and summarizing them, which suits AI drafting. At the same time, watch for the following.
- Fact checking: the physician confirms that test values, dates, drug names and doses match the chart
- Filling in what is not recorded: check that history or findings not in the chart have not been added as plausible text
- Purpose of referral: AI infers the reason for referral from the chart, so the physician confirms and corrects, in their own words, what they want the recipient to do
- Suspected diagnoses: check that confirmed and suspected diagnoses are distinguished
- Handling personal information: if patient information is processed by an external AI service, confirm that the contract and settings follow the guidelines on safety management of medical information
A referral letter goes to another institution under the physician's name. Treat AI-generated text as a draft and set an operating rule that the physician reviews it before it is issued.
Summary
- "Referral letter" is the everyday name; in insurance-covered care it is called a medical information letter and is prepared on Attached Form 11 or an equivalent format
- The medical information provision fee (I) is 250 points, billed once a month per patient per receiving institution when referring with the patient's consent and a document describing the clinical situation; attach a copy to the chart
- Write the purpose of referral specifically: what you want the recipient to do
- Onjishi and okika are both wakizuke added beside the addressee's name to show respect, and are widely used in medicine. No official rule decides between them, so standardize within your clinic
- Under the FY2026 revision, the physician's signature or name and seal may be omitted from the second time onward or when the letter is handed over directly
- For AI drafts, the physician checks facts, the purpose of referral and suspected diagnoses before issuing
For how generative AI can produce referral letters and discharge summaries, see What Generative AI Can Do for Medical Documents; for templates and AI, see AI Document Creation and Templates. For medical information letters in psychiatry, see Automating Psychiatric Paperwork and Referral Letters, and for referrals from internal medicine to ophthalmology and handling replies, see The Ophthalmology Cooperation Enhancement Addition.
Pottech provides an AI EMR and AI document creation for clinics that drafts referral letters and other documents from chart records for the physician to review and finalize. If documentation workload is a concern, please feel free to contact us.
Frequently Asked Questions
- Q. How is 御侍史 read?
- A. It is read 'onjishi', and sometimes 'gojishi'. The Digital Daijisen dictionary describes it as having the same meaning as jishi, a term written beside the addressee's name, and notes it is widely used in the medical field.
- Q. How do onjishi and okika differ?
- A. Both are honorific terms written beside the addressee's name. Jishi comes from 'presenting through your secretary', and kika from 'placing it under your desk'. No law sets how to choose between them; follow your institution's or region's custom.
- Q. How do I address a letter when I don't know the physician's name?
- A. A common form is '[Hospital] [Department] Attending Physician-sensei Onjishi'. The MHLW Attached Form 11 has a field reading 'Attending physician, Department of ___, dono'.
- Q. Is a referral letter different from a medical information letter?
- A. They usually refer to the same document. 'Referral letter' is the everyday term; in insurance-covered care the document attached to a referral is called a medical information letter and is prepared on Attached Form 11 or an equivalent format.
- Q. How many points can be billed for a referral letter?
- A. If the requirements are met, the medical information provision fee (I) is 250 points, once a month per patient per receiving institution. Patient consent and attaching a copy of the letter to the chart are required. Referrals to institutions with a special relationship cannot be billed.
参考・出典
- 厚生労働省「診療報酬の算定方法の一部を改正する件」（令和8年厚生労働省告示第69号）医科診療報酬点数表（B009 診療情報提供料(Ⅰ)、B010 診療情報提供料(Ⅱ)、B011 連携強化診療情報提供料） https://www.mhlw.go.jp/content/12400000/001686842.pdf
- 厚生労働省保険局医療課「診療報酬の算定方法の一部改正に伴う実施上の留意事項について」（令和8年3月5日保医発0305第6号）別添1（B009） https://www.mhlw.go.jp/content/12400000/001757385.pdf
- 厚生労働省保険局医療課 事務連絡「令和8年度診療報酬改定関連通知及び官報掲載事項の一部訂正について」（令和8年5月1日）別紙様式11の2 https://www.mhlw.go.jp/content/12400000/001700249.pdf
- 厚生労働省「令和8年度診療報酬改定について」個別改定事項（紹介状なしで受診する場合等の患者定額負担、事務等の簡素化・効率化） https://www.mhlw.go.jp/content/12400000/001681336.pdf
- 医療法（昭和23年法律第205号）第1条の4 https://laws.e-gov.go.jp/law/323AC0000000205
- 保険医療機関及び保険医療養担当規則（昭和32年厚生省令第15号）第16条・第16条の2 https://laws.e-gov.go.jp/law/332M50000100015
- 全国健康保険協会 健康づくりコラム（紹介状なしで大病院を受診した場合の特別の料金） https://www.kyoukaikenpo.or.jp/health_promotion/column/r07/002/
- コトバンク「侍史」（デジタル大辞泉、精選版日本国語大辞典） https://kotobank.jp/word/侍史
- コトバンク「御侍史」（デジタル大辞泉） https://kotobank.jp/word/御侍史
- コトバンク「机下」「御机下」（デジタル大辞泉、精選版日本国語大辞典） https://kotobank.jp/word/机下 / https://kotobank.jp/word/御机下
- コトバンク「脇付」 https://kotobank.jp/word/脇付