Regulations Governing the National Health Insurance Dispute Mediation Article 14

The application for mediation of the benefit case requires the applicant to fill out the petition stating the following matters with his agent’s or his own signature or seal:1. The applicant’s name, date of birth, domicile, or place of residence, and ID No. If the applicant is a juridical person or an organization with managers or representatives, the juridical person or organization’s name, office or business address, and the manager or representative’s name, date of birth, domicile, or place of residence.2. If the applicant has an agent, he or she shall present a written form of power of attorney at the first place of the administrative appeal conduct. A power of attorney shall include the agent’s name, date of birth, domicile, or place of residence, and ID No.3. Claims4. Facts and reasons for mediation application5. The date of receiving or knowing the Insurer’s original Notice of Assessment (MM/DD/YYYY)6. The evidence. If the evidence is a written document, a transcript or copy is required.7. Transcripts or copies of the Insurer’s original Notice of Assessment document and the related documents or materials8. MM/DD/YYYYIn Subparagraph 4 of the preceding paragraph, facts & reasons shall be stated respectively, and the related arguments shall be stated one by one; if the application materials are in a foreign language, a Chinese version is required.