The application for mediation of the medical expenses case requires the applicant to fill out the petition and the detailed list (see Appendix 1 and 2) stating the following matters with his seal:1. The name and code of the contracted medical care institution and the medical personnel who is in charge of the institution.2. Claims3. Facts and reasons for mediation application4. The date of receiving or knowing the Insurer’s recheck notification (MM/DD/YYYY)5. The medical record and other related certifications. The transcripts or copies of materials in written form are required.6. Transcripts or copies of the Insurer’s recheck notification document and the related documents or materials7. MM/DD/YYYYThe facts and reasons referred to in Subparagraph 3 of the preceding paragraph shall be written in the columns specified by the format.An applicant submitting Appendix 2 (details of dispute mediation case) together with relevant documents and materials as prescribed in Paragraph 1 of this Article in electronic form through the system designated by the NHI Dispute Mediation Committee is exempted from providing those documents and materials in paper and physical form. However, the NHI Dispute Mediation Committee may, as it deems necessary, request the applicant to submit those documents and materials in paper and physical form.‧Appendix 1.pdf‧Appendix 1.odt‧Appendix 2.pdf‧Appendix 2.odtAttachment 1 Dispute Mediation Petition for Medical Expense of National Health Insurance.PDFAttachment 2 Details of Dispute Mediation Case for Medical Expense of Contracted Medical Care Institution.PDF