The Doctor's Opinion Letter for Care Certification in Japan: What to Do With No Regular Doctor

What Is the Shujii Ikensho, and Who Actually Writes It?

The shujii ikensho (主治医意見書, doctor's opinion letter) is a standardized medical report that a physician completes for the municipality, and no certification decision is finalized without one.

Under Article 27 of Japan's Long-Term Care Insurance Act, once a family files a care-need certification application, the municipality itself writes to the named physician and requests the opinion letter directly. The family's job is to name a doctor on the application form, not to obtain, carry, or deliver any paperwork. This surprises many overseas families, who expect the process to work the way it might elsewhere, with the applicant collecting a letter from a clinic and submitting it themselves.

The letter covers the diagnosis behind the need for care, the course of any illness, cognitive function, and daily-life limitations as the doctor observes them, and it becomes one of two inputs, alongside the in-person assessment visit, that decides the certified level. There is no fee charged to the applicant for the opinion letter itself; the municipality pays the physician directly as part of the certification process, so cost is not the obstacle here. The obstacle, for a meaningful share of families, is simpler and more basic: which doctor gets the letter.

This single requirement is also why the process differs from an ordinary medical referral. A family searching for care in Japan for the first time is usually trying to find a doctor their parent can actually talk to for day-to-day health needs. This article is about a narrower and more procedural problem: securing whichever doctor the certification system will accept as the one who writes this one document, even when no such doctor yet exists.

Why a Missing Doctor Can Stall the Whole Application

If the application form lists no physician, or lists one who will not respond, the certification cannot move to a decision, because the doctor's opinion is a mandatory input alongside the survey visit.

Japan's statutory target is a certification result within about 30 days of the application date, and coverage is backdated to the application date once a level is confirmed, so a slow start does not lose benefit days. In practice, however, many municipalities miss the 30-day target specifically when a doctor's opinion is late or nobody has yet been named, and the city can issue a formal notice extending the decision period rather than deciding without the letter.

This matters most for two family situations that come up constantly with parents supported from abroad: a parent who moved back to Japan after years overseas and has no local doctor at all, and a parent whose only established physician is still overseas and cannot complete a Japanese government form. Both are common, and neither is unusual enough that the ward office has not seen it before; the fix in each case, covered next, does not require the family to solve it alone.

Families juggling a parent's overall health picture from a distance, including house-call doctors and visiting nurses once care starts, often assume the same doctor automatically becomes the certification's shujii. That is common but not guaranteed. Whoever is named on the application, and who actually responds to the municipality's request, is the one whose opinion counts, so confirming that a doctor has agreed to be named is worth doing before the application is filed, not after.

Comparing the Three Starting Points

Whether a parent already has a doctor, has none, or has one who lives overseas changes who the family needs to contact first, not whether certification is possible.

• A single completed visit is generally enough for a doctor to be named as the shujii for this purpose; a long-standing relationship is not required.
• The doctor does not need to be a specialist in the parent's main condition; general practice or internal medicine clinics write these letters routinely.
• Whichever path applies, naming a doctor early is the one action that keeps the 30-day clock from stretching further.

Getting a City-Assigned Doctor When There Is No Kakaritsuke Doctor

When a parent has no established physician, the ward office's long-term care insurance section can point the family to a doctor willing to write the opinion letter, usually through the local medical association.

The standard route is to ask directly at the municipal window handling the care-need certification application: "My parent has no regular doctor; can you refer one for the opinion letter?" Local medical associations across Japan work with municipalities on exactly this situation, maintaining lists of clinics willing to take on new patients specifically for certification purposes. This is a routine administrative referral, not an emergency medical service, so it does not require the parent to already be in crisis.

In practice, most families end up booking a first appointment at a nearby internal medicine or general clinic, mentioning that the visit is for a long-term care certification opinion letter, and the clinic takes it from there once the municipality's request arrives. A single visit that establishes basic findings, current medications, mobility, and cognitive status is usually sufficient groundwork for the doctor to complete the form; the doctor is not expected to have years of history with the patient.

Families should not wait for a health crisis to make this first contact. Establishing a local doctor before an urgent need arises means the certification application, when it is eventually filed, already has a named physician rather than starting the search for one from scratch under time pressure.

When the Only Doctor Is Overseas

A doctor practicing outside Japan cannot complete or return a Japanese municipal opinion letter, so the family has to establish a Japan-based doctor before or during the application, even for a parent who arrived very recently.

The practical workaround is the same first step as having no doctor at all: book an appointment with a local clinic, explain that the visit is connected to a care-need certification application, and let that doctor's own examination form the basis of the opinion letter. Overseas medical records, discharge summaries, or a translated diagnosis history are useful background for the new doctor to review, and bringing them to the first appointment can speed up the visit, but they do not replace an in-person Japanese examination; the letter reflects the Japan-based doctor's own findings, not a transcription of foreign paperwork.

Families who are still overseas themselves, coordinating a parent's care from a distance, sometimes ask whether the process can be handled entirely by phone or mail before anyone lands in Japan. It generally cannot: the physician writing the opinion letter needs to have actually examined the patient, so the first local doctor's visit has to happen with the parent present in Japan, even if a family member abroad is managing everything else about the application.

Once that first local doctor's visit happens and the doctor is named on the certification form, the situation converges with the standard process: the municipality writes to that doctor directly, and the family's overseas relative can return to coordinating from a distance for everything that follows.

How Long the Letter Takes, and What to Do If It Is Late

There is no fixed number of days a doctor is given to return the opinion letter, but a slow or missing letter is the single most common reason certification runs past the 30-day statutory target.

Once the municipality sends its request, most doctors return the completed opinion letter within a few weeks, though a busy clinic, a doctor unfamiliar with the form, or a parent whose case needs additional tests can extend that. If weeks pass with no update, the family or the parent's care manager, once one is assigned, can ask the municipality's long-term care insurance section to follow up with the clinic directly; municipalities generally have more leverage to prompt a response than an individual family does.

Because coverage is backdated to the application date once a decision is made, a delayed letter costs time and certainty, not benefit days already used. Even so, treating the doctor's opinion as the pacing item, rather than assuming the wait is entirely on the municipality's side, is the more useful mental model: following up on the letter is usually more productive than following up on the assessment visit, which tends to happen faster.

If a parent's situation changes substantially while waiting, for instance a hospitalization, both the survey and the doctor's opinion can be updated, and cases tied to a recent hospital discharge are the ones where certification staff most often expect and accommodate a fresh, more current opinion.

When the Doctor's Opinion and the Assessment Visit Disagree

The certification committee weighs the doctor's opinion letter and the in-person assessment together, so a mismatch between the two does not automatically favor either one.

The assessment visit produces a standardized questionnaire result that feeds a computer-generated first-pass rating, and the local certification committee then reviews that result alongside the doctor's opinion letter and any additional written notes from the assessor before deciding the final level. A parent who understates their own limitations during a short visit, a known and common pattern, can end up with a survey result that reads more capable than the doctor's letter describes, or the reverse: a doctor who has not seen the patient recently may describe a milder picture than a home visit reveals.

When the two clearly diverge, the committee's role is specifically to reconcile them rather than mechanically average them; a well-documented doctor's letter that names concrete difficulties, memory lapses, unsteady walking, or specific unsafe incidents, can shift a result that the assessment visit alone made look better than reality. This is one reason briefing the doctor before the appointment, describing the same daily struggles the family sees at home, matters as much as preparing for the survey visit itself.

If the certified level still comes back lower than the family believes reflects the parent's real situation, the appeal and level-change process is the next step, and a more detailed doctor's letter at that stage, prepared with the same care as the first one, is typically the single strongest piece of new evidence a family can add.

Deciding What To Do Before Filing

The one decision every family should make before submitting the certification application is whether a physician is already confirmed and willing to be named, because everything else in the process assumes that box is filled.

• If a regular doctor already exists in Japan: confirm they are willing to accept the municipality's request before naming them on the form.
• If no regular doctor exists: contact the municipal long-term care insurance window for a referral, and book a first visit before or immediately after filing.
• If the only established doctor is overseas: book a first Japan-based clinic visit as early as possible, bringing translated records as background, and expect that visit, not the overseas history, to form the opinion letter.
• In every case: naming a doctor early is the single action most likely to keep the process inside its 30-day target, and the outcome remains backdated to the filing date regardless of how long the letter takes.