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[{"$nulls":12},"被保険者",null,null,null,"療養費支給申請書"]
[{"$nulls":12},"被扶養者"]
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[null,null,null,"（この申請書に添えなければならない書類）",null,"（説明）",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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[{"$nulls":7},"記号・番号",{"$nulls":5},"番号"]
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[{"$nulls":7},"被保険者氏名",{"$nulls":5},"（フリガナ）",{"$nulls":13},"生年月日",{"$nulls":4},"\n年",null,null,"\n月",null,null,"\n日"]
[3,2,1]
[]
[{"$nulls":7},"被保険者の住所"]
[{"$nulls":13},"〒",null,null,null,"-",{"$nulls":5},"丁目、番地、アパート名等詳細に記入してください。"]
[3,2,1,null,"又は手当を受けた場合にその診療又は手当に要した費用を申請するものです。","この申請書は被保険者又は被扶養者が保険医療機関等について診療を受けることが困難な場合又は保険医療機関等以外の医師又はその他の者の診療"]
["コルセット等に関する支給申請のときは装着を必要と認めた医師の証明書及び領収書","血液代に関する支給申請のときは輸血を必要と認めた医師の証明書及び血液代金の領収書","療養に要した費用については①医師又は市町村から記入、押印を受けた領収書②診療報酬明細書"]
[{"$nulls":7},"電話番号",{"$nulls":10},"-",{"$nulls":5},"-"]
[]
[{"$nulls":7},"申請が被扶養者の\n場合はその者の氏名",{"$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":7},"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"]
[]
[{"$nulls":7},"発病の原因"]
[]
[{"$nulls":7},"傷病の経過"]
[]
[{"$nulls":7},"仕事中又は第三者行為\nによる傷病ですか？",{"$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"]
[]
[]
[{"$nulls":7},"受診した医療機関等の\n名称、所在地及び\n診療した医師等の氏名",{"$nulls":5},"名称"]
[]
[{"$nulls":13},"所在地"]
[]
[]
[{"$nulls":13},"医師等の氏名"]
[]
[{"$nulls":7},"診療又は手当の期間",{"$nulls":5},"年　　　　月　　　　日から",{"$nulls":11},"日間",null,"うち入院　した期間",null,null,"年　　　　月　　　　　日から"]
[]
[{"$nulls":13},"年　　　　月　　　　日まで",{"$nulls":16},"年　　　　月　　　　　日まで"]
[]
[{"$nulls":7},"診療又は手当の内容"]
[]
[]
[{"$nulls":7},"申請の理由",{"$nulls":6},"1. 加入して間もなく医療機関を受診し、資格を確認できなかったため"]
[{"$nulls":14},"2. 資格確認書の交付を受けているが、資格確認書の持参を忘れたため"]
[{"$nulls":14},"3. 他の保険者で資格喪失後に受診し、返還した医療費を療養費として申請するため"]
[{"$nulls":14},"4. 治療用装具、治療用眼鏡等を作成したため"]
[{"$nulls":14},"5. その他（理由：　　　                          　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[]
[{"$nulls":7},"被保険者　　　　　銀行口座",null,"□マイナポータル等で事前登録した公金口座を利用します。（利用する場合は□にチェック、利用しない場合は下記の欄を記入。）"]
[{"$nulls":9},"注）口座情報の反映には登録から数日を要します。"]
[{"$nulls":15},"銀行\n金庫\n農協",{"$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":26},"口座名義",null,null,"(",{"$nulls":8},")"]
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[{"$nulls":8},"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":13},"￥"]
[{"$nulls":7},"健保組合処理欄"]
[{"$nulls":8},"款　項　目",{"$nulls":14},"取　　得",{"$nulls":4},"　　　　　年　　　　　月　　　　　日　　"]
[]
[{"$nulls":8},"支　給　決　定",{"$nulls":14},"喪　　失",{"$nulls":4},"　　　　　年　　　　　月　　　　　日　　"]
[{"$nulls":8},"年　　月　　日"]
[{"$nulls":8},"支　　　　　払",{"$nulls":14},"療養費の別",{"$nulls":4},"　　　1.　　 立替払等\n　　　2.　　 治療用装具\n　　　3.　　 生　血"]
[{"$nulls":8},"年　　月　　日"]
[{"$nulls":8},"支給額計算"]
[]
[]
[{"$nulls":8},"備　　　　　　考",{"$nulls":24},"受  付  日  付  印"]