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[{"$nulls":11},"被保険者",null,null,null,"療養費支給申請書（はり・きゅう・あんま・マッサージ用）"]
[{"$nulls":11},"被扶養者"]
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[{"$nulls":6},"（この申請書に添えなければならない書類）",null,"被保険者等",{"$nulls":5},"記号",{"$nulls":9},"記号番号が分からない場合はマイナンバーを記入してください"]
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[{"$nulls":8},"記号・番号",{"$nulls":5},"番号"]
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["※④⑤については、該当する場合のみ提出してください。","⑤","④","③","②","①",null,null,"被保険者氏名",{"$nulls":5},"（フリガナ）",{"$nulls":13},"生年月日",{"$nulls":4},"\n年",null,null,"\n月",null,null,"\n日"]
[null,"１年以上・月１６回以上施術継続理由・状態記入書","往療状況（計算の明細・理由等）が確認できる書類","施術内容が確認できる書類（施術内容明細書又は施術所作成の書類）","領収書（原本）","保険医の同意書（原本）※治療が継続する場合、6カ月ごとに提出してください。"]
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[{"$nulls":8},"被保険者の住所"]
[{"$nulls":14},"〒",null,null,null,"-",{"$nulls":5},"丁目、番地、アパート名等詳細に記入してください。"]
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[{"$nulls":8},"電話番号",{"$nulls":10},"-",{"$nulls":5},"-"]
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[{"$nulls":8},"施術を受けた者の\n氏名",{"$nulls":13},"生年月日",{"$nulls":4},"\n年",null,null,"\n月",null,null,"\n日","被保険者\nとの続柄"]
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[{"$nulls":8},"傷病名",{"$nulls":16},"発病又は負傷の\n年月日",{"$nulls":7},"年",null,null,"月",null,null,"日"]
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[{"$nulls":8},"発病の原因"]
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[{"$nulls":8},"傷病の経過"]
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[{"$nulls":8},"仕事中又は第三者行為\nによる傷病ですか？",{"$nulls":5},"　□は　い　⇒　□仕事中（業務上・通勤途上）　□第三者行為（交通事故等）　\n　□いいえ"]
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[{"$nulls":8},"施術期間",{"$nulls":8},"年",null,null,"月",null,null,"日から",{"$nulls":4},"年",null,null,"月",null,null,"日まで",null,null,null,"日間",null," "]
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[{"$nulls":8},"施術日",{"$nulls":5},"（　　　　）",null,null,null,"月",null,null,null,"※施術を受けた日付に○を付けてください。"]
[{"$nulls":14},"1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31"]
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[{"$nulls":8},"施術に要した\n費用の額",{"$nulls":11},"円",null,"公費負担の適用",{"$nulls":6},"あり（自己負担",{"$nulls":5},"割）",null,"・","なし"]
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[{"$nulls":8},"施術の内容"]
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[{"$nulls":8},"施術所名\n住所及び施術者名",{"$nulls":5},"名称"]
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[{"$nulls":14},"住所"]
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[{"$nulls":14},"施術者名"]
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[{"$nulls":8},"被保険者　　　　　銀行口座",null,"□マイナポータル等で事前登録した公金口座を利用します。（利用する場合は□にチェック、利用しない場合は下記の欄を記入。）"]
[{"$nulls":10},"注）口座情報の反映には登録から数日を要します。"]
[{"$nulls":16},"銀行\n金庫\n農協",{"$nulls":7},"本店\n支店\n出張所",null,null,"普通",null,"口座番号",null,null,"(",{"$nulls":6},")"]
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[{"$nulls":27},"口座名義",null,null,"(",{"$nulls":8},")"]
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[{"$nulls":9},"支　給　金　額",{"$nulls":14},"常務理事",null,null,null,"事務長",null,null,null,"係",null,null,null,"確認"]
[{"$nulls":14},"￥"]
[{"$nulls":8},"健保組合処理欄"]
[{"$nulls":9},"款　項　目",{"$nulls":14},"取　　得",{"$nulls":4},"　　　　　年　　　　　月　　　　　日　　"]
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[{"$nulls":9},"支　給　決　定",{"$nulls":14},"喪　　失",{"$nulls":4},"　　　　　年　　　　　月　　　　　日　　"]
[{"$nulls":9},"年　　月　　日"]
[{"$nulls":9},"支　　　　　払"]
[{"$nulls":9},"年　　月　　日",{"$nulls":24},"受  付  日  付  印"]
[{"$nulls":9},"支給額計算"]
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[{"$nulls":9},"備　　　　　　考"]