The Referral-Letter (Shokaijo) System
The referral letter Japan residents carry to large hospitals, the 紹介状 (shōkaijō, "referral letter"), is a formal clinical handoff from a local doctor to a hospital specialist.12 Without it, a first visit to a qualifying large hospital costs thousands of yen extra and waits behind referred patients.34
Procedures, fees, and requirements can change. Confirm current details at the Ministry of Health, Labour and Welfare (MHLW). This article is general information, not medical advice; for your specific condition, consult a licensed physician.
Overview
The shokaijo is the standard paper bridge between community care and hospital care. A clinic physician writes it when a case needs specialist testing or treatment, and the patient carries it to the destination hospital.1
Referral-focus hospitals are built around receiving exactly these patients. They still accept walk-ins without a letter, but a no-letter visit draws a fixed special charge beside the ordinary insured copay.3
What the referral letter is
The letter is a formal clinical document prepared by the referring clinic. It traditionally takes a set form bearing the clinic stamp, with the doctor's own clinical notes attached.12 Hospitals file it under its formal name, the 診療情報提供書 (shinryō jōhō teikyōsho, "patient referral document").12
Preparing the document carries a service fee of 2,500 yen in total, of which a 30-percent-copay patient pays 750 yen (as of 2026-06; confirm current figures with the issuing clinic).2 The 30 percent band covers insured persons up to age 69, with lower bands for young children, ages 70 to 74, and 75 and over (as of 2026-06).2
What the letter carries
The letter states the referral purpose, the illness name, and the prior history. It also records the course the clinic already ran: interview findings, symptom progress, and test results.1
That head start lets the hospital grasp the patient's status on arrival. The hospital proceeds from the clinic's work instead of repeating the workup from zero.1
The practical flow: clinic to hospital
The standard path has four steps.1 First, the patient visits the かかりつけ医 (kakaritsuke-i, "family doctor or regular physician"). Second, the clinic judges that specialist care is needed and issues the letter.
Third, the patient visits the hospital with the letter. Fourth, after hospital care ends, the hospital writes a reverse referral back to the clinic for follow-up.1
The following chart shows the handoff from the patient's side:
The clinic identifies the suitable specialist or hospital before writing. The patient does not choose the destination blind, since the referral names where the case should go.1
Who carries what, and where it goes
The default pattern is patient-carried. The clinic hands the sealed letter to the patient, who brings it to the destination hospital reception on the visit day.2
In major hospital networks, the clinic may instead transmit the referral directly or book the hospital appointment from the clinic side. Registered-physician facilities take appointments from clinic doctors, with some exceptions, and listed departments run telephone reception.4
The return path back to the clinic
After specialist treatment or testing ends, the hospital writes a 逆紹介 (gyaku shōkai, "reverse referral") back to the kakaritsuke-i. The local doctor then resumes follow-up care.1
Continued attendance at the hospital under the hospital doctor's own treatment instruction stays ordinary care. Only by-choice retention after a reverse-referral offer draws the revisit surcharge.1
What the letter costs and what it waives
Holding the letter waives the fixed non-referral surcharge at qualifying large hospitals. That waiver is the letter's financial function, and it is worth far more than the document fee.31
The national floor amounts for the 選定療養費 (sentei ryōyōhi, "fixed special charge for treatment of the patient's choice") are 7,000 yen for a medical first visit and 5,000 yen for a dental first visit (as of 2024-01-01; confirm current figures with the MHLW).5 Return visits draw 3,000 yen for medical and 1,900 yen for dental where the patient stays by choice after being offered an onward referral (as of 2024-01-01).5 Each figure is charged in addition to the ordinary insured copay.5
| Item | Amount (national floor) | As of | Notes |
|---|---|---|---|
| First visit, medical, no referral | ¥7,000 | 2024-01-015 | Charged beside the regular copay |
| First visit, dental, no referral | ¥5,000 | 2024-01-015 | Charged beside the regular copay |
| Return visit, medical, stayed by choice | ¥3,000 | 2024-01-015 | After an onward-referral offer |
| Return visit, dental, stayed by choice | ¥1,900 | 2024-01-015 | After an onward-referral offer |
The figures above are minimums, and each hospital sets its own amount at or above the floor. Soka Municipal lists 7,700 yen medical and 5,500 yen dental for a first visit with a 3,300 yen medical revisit charge (as of 2024-10-01), while Hiroo Hospital lists the floor figures exactly (as of 2024-01-01).15
Prominent hospitals set higher figures. The Japanese Red Cross Medical Center lists 11,000 yen for first and return visits (as of 2020-11-01), and Tsukuba Medical Center lists 11,000 yen for a no-letter first visit (as of 2023-10).64 Tax-included display also differs by hospital, so confirm the exact figure on the specific hospital's page.5
Going without a referral
A no-letter patient may still be seen at most large hospitals. The visit simply costs the surcharge beside the regular copay.31
The visit may also be slower. Appointment holders take priority, so waiting times run longer for walk-ins without letters.4 Specialist absence, surgery schedules, or full capacity can push the visit to another day, and some departments cannot be seen at all without a letter.1
Adding another department inside the same hospital without an in-hospital referral counts as a first visit. That visit draws the first-visit surcharge even though the patient already attends the hospital.5 An in-hospital referral from the attending doctor, or a clinic letter for the new department, satisfies the requirement.5
Exemptions cover referral holders, emergency transport and same-visit admission, in-hospital department referrals, public-assistance recipients, specified public-expense cases, detailed-examination orders after screening, and work or public-duty accidents.16
Good to know
Keep the referral envelope sealed
Preparing the letter costs 2,500 yen in total, with a 30-percent-copay patient paying 750 yen (as of 2026-06; confirm current figures with the issuing clinic).2 Hand the sealed envelope to the hospital reception unopened.
The reissue practice after a broken seal is inconsistently reported across practitioner sources. Treat the envelope as single-use and avoid opening it for a look.
Electronic handoff does not remove the patient step
Where the clinic books or transmits directly, the patient still shows up with the insurance credential and any handed paperwork on the booked day. The handoff method never replaces the visit itself.4
Confirm the booking route before traveling. Registered-physician facilities take appointments from the clinic side with exceptions, and listed departments run telephone reception.4
No-letter walk-ins wait behind referred patients
Appointment holders take priority, so a no-letter walk-in faces longer waits plus the surcharge.4 Same-day capacity can also push the visit to another day when specialists are absent or lists are full.1
When the schedule is tight, the letter functions as a queue position as well as a fee waiver. Arriving with one shortens both the bill and the wait.14
See also
- Clinic vs. Hospital: The Two-Tier System
- The Freedom-of-Access Norm: Seeing Any Doctor in Japan Without a Referral
- Maina-Hokensho: Health Insurance Card Going Digital
- Selecting a Local Clinic as Primary Care
- Booking a Doctor in Japan
- What to Bring to a Doctor's Visit