Guides · 紹介状 · shōkaijō
Referral Letters, Specialists, and Second Opinions — Moving Up the System
Japanese healthcare is built as a pyramid — clinics at the base, university and regional hospitals at the top — and the document that moves you between the layers is a sealed envelope called the referral letter (紹介状, shōkaijō). Use it well and the system opens smoothly; ignore it and you pay extra to wait longer.
What the letter is
Formally a 診療情報提供書 (medical information document), the referral letter contains your history, findings, test results, current medications and the referring doctor's question to the specialist. It is a standardized, insurance-billed document — the clinic charges roughly ¥750 as your 30% share — and it typically comes sealed, addressed either to a named hospital or "to whom it may concern" (a perfectly usable format if you want to choose the hospital yourself).
Its practical value is threefold: it waives the large-hospital selection fee (¥7,700+ at 200-bed-plus regional hub hospitals and university hospitals), it gets you a proper appointment slot instead of an unbooked-walk-in wait, and it means the specialist starts from your data instead of from zero — often with your imaging on a disc enclosed.
When you need one, and when you don't
You do not need a referral to see most community specialists — dermatology, ENT, ophthalmology, gynecology, orthopedics all run street-level clinics you can walk into directly. That is the pyramid's base working as designed.
You effectively do need one for: university and large regional hospitals (or you pay the selection fee and wait), specific named departments within them, advanced diagnostics your clinic can't order, and surgical consultations. The clean mental model: community clinic for the first look, referral upward when the problem exceeds the clinic — and your clinic doctor decides that willingly. Asking "should this be seen at a hospital?" is a normal question, not a challenge.
Coming the other way, expect reverse referral (逆紹介): once a hospital stabilizes you, they will actively push your routine follow-up back down to a local clinic, keeping their own slots for acute work. This is policy, not rejection — large hospitals now also charge extra for repeat visits that should have moved back to a clinic.
How to ask
At any clinic visit: 「紹介状を書いていただけますか」 (could you write me a referral letter?). Reasonable triggers include symptoms not improving on current treatment, a finding that needs imaging or biopsy, a checkup result marked 要精密検査, or simply wanting a specific hospital for an upcoming procedure. Doctors write these constantly; no diplomacy is required. If you already know the target hospital, say so — many hospitals let the clinic book your specialist appointment directly, which is the smoothest path of all.
Bring the sealed envelope, unopened, to the hospital's 初診 (first visit) reception with your insurance credential. Opening it yourself isn't illegal — it's your information — but hospitals prefer it sealed, and there is rarely a reason to break the seal.
Second opinions: normal, but know the two routes
Wanting another specialist's view — typically before cancer treatment or major surgery — is accepted and has formal machinery. There are two routes with very different price tags:
- The formal second-opinion consultation (セカンドオピニオン外来) at large hospitals: you stay under your current doctor, who prepares a referral letter and your records; the second hospital reviews and advises but does not treat. This is not covered by insurance — typically ¥20,000–50,000 for 30–60 minutes, self-pay.
- Transferring care: if you actually intend to switch hospitals, an ordinary referral to the new hospital's regular outpatient clinic is insurance-covered like any visit. Same expertise, different framing.
Two notes from inside the system. First, ask your current doctor openly — 「セカンドオピニオンを受けたいのですが」 — rather than starting again elsewhere in secret; the letter and data they prepare is what makes the second opinion meaningful, and the request is routine enough that offense is genuinely rare now. Second, a second opinion that agrees with the first is not wasted money; before major treatment, concordance is exactly what you were buying.
If you're leaving Japan mid-treatment
The same document works in reverse: ask for a referral letter in English (英文の紹介状・診療情報提供書) summarizing diagnosis, treatment and results for your next doctor abroad. Most hospitals produce one for a self-pay fee of a few thousand yen. Copies of imaging on disc are usually available on request. Arrange this before your last appointment, not after you've flown.
General information. Fee amounts follow the national schedule and individual hospital pricing; confirm second-opinion fees with the hospital's consultation desk (患者相談窓口) — the desks themselves usually have experience with foreign patients.