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{"sheet":"移送費支給申請書","index":0,"n_rows":68,"n_cols":33,"rows_kept":68,"cut":false,"hidden":false,"merged":[[46,1,47,6],[46,7,47,17],[37,26,39,26],[37,30,39,31],[37,32,39,32],[37,27,39,28],[37,29,39,29],[37,23,39,25],[69,24,69,32],[28,1,34,6],[44,1,45,6],[44,7,45,32],[61,17,62,21],[61,22,62,32],[37,1,39,6],[46,18,47,22],[46,23,47,32],[37,21,39,22],[65,2,66,6],[56,2,58,6],[56,17,58,17],[67,2,69,6],[67,7,67,10],[69,17,69,23],[56,21,58,21],[56,25,58,25],[56,29,58,29],[58,1,67,1],[59,2,60,6],[59,17,60,21],[59,22,60,32],[61,2,61,6],[62,2,62,6],[63,2,63,6],[64,2,64,6],[51,26,52,31],[51,32,52,32],[53,20,54,22],[53,23,54,23],[53,24,54,31],[53,32,54,32],[37,7,39,20],[35,27,36,32],[49,1,54,2],[51,3,54,8],[51,9,54,10],[51,11,54,16],[51,17,54,19],[51,20,52,21],[51,22,52,24],[51,25,52,25],[30,7,32,10],[30,11,32,32],[33,7,34,10],[33,11,34,32],[35,1,36,6],[40,1,43,6],[41,17,41,32],[42,7,43,32],[35,20,36,22],[35,23,36,26],[19,32,20,32],[21,1,24,6],[21,7,24,32],[25,1,27,6],[25,7,27,32],[28,7,29,10],[28,11,29,32],[16,27,18,29],[16,30,18,32],[19,1,20,6],[19,7,20,17],[19,18,20,22],[19,23,20,25],[19,26,20,26],[19,27,20,28],[19,29,20,29],[19,30,20,31],[14,19,15,32],[16,1,18,6],[16,7,18,14],[16,15,18,16],[16,17,18,19],[16,20,18,20],[16,21,18,22],[16,23,18,23],[16,24,18,25],[16,26,18,26],[7,32,9,32],[8,7,9,20],[10,1,13,6],[11,17,11,32],[12,7,13,32],[14,1,15,6],[14,7,15,11],[14,12,15,12],[14,13,15,17],[14,18,15,18],[7,1,9,6],[7,7,7,20],[7,21,9,22],[7,23,9,25],[4,25,5,25],[3,1,4,6],[4,20,5,20],[4,21,5,21],[0,10,1,22],[3,7,4,16],[3,17,3,32],[4,18,5,18],[4,19,5,19],[5,1,6,6],[5,7,6,16],[4,23,5,23],[4,24,5,24],[4,31,5,31],[35,7,36,15],[35,16,36,19],[4,26,5,26],[4,28,5,28],[4,29,5,29],[4,30,5,30],[7,26,9,26],[7,27,9,28],[7,29,9,29],[7,30,9,31]],"flags":["formulas_cached_only"]}
[{"$nulls":6},"被保険者",null,null,null,"移送費支給申請書"]
[{"$nulls":6},"被扶養者"]
[]
[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"]
[]
[null,"記号・番号",{"$nulls":5},"番号"]
[]
[null,"被保険者氏名",{"$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,"被保険者の住所"]
[{"$nulls":7},"〒",null,null,null,"-",{"$nulls":5},"丁目、番地、アパート名等詳細に記入してください。"]
[]
[]
[null,"電話番号",{"$nulls":10},"-",{"$nulls":5},"-"]
[]
[null,"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"]
[]
[]
[null,"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"]
[]
[null,"発病又は負傷の原因"]
[]
[]
[]
[null,"仕事中又は第三者行為\nによる傷病ですか？",{"$nulls":5},"　□は　い　⇒　□仕事中（業務上・通勤途上）　□第三者行為（交通事故等）　\n　□いいえ"]
[]
[]
[null,"受診した医療機関等の\n名称、所在地及び\n診療した医師等の氏名",{"$nulls":5},"名称"]
[]
[{"$nulls":7},"所在地"]
[]
[]
[{"$nulls":7},"医師等の氏名"]
[]
[null,"移送年月日",{"$nulls":5},"        年　　　　月　　　　日",{"$nulls":8},"移送回数",null,null,null,"　　　　回",null,null,"移送費用",null,null,null,"　　　　　　　　円"]
[]
[null,"付添人がいる場合は\nその者の氏名",{"$nulls":19},"生年月日",{"$nulls":4},"\n年",null,null,"\n月",null,null,"\n日"]
[]
[]
[null,"付添人の住所"]
[{"$nulls":7},"〒",null,null,null,"-"]
[]
[]
[null,"移送経路"]
[]
[null,"移送方法",{"$nulls":16},"移送距離",{"$nulls":4},"　　　　㎞"]
[]
[]
[null,"被保険者　　　　　銀行口座",null,"□マイナポータル等で事前登録した公金口座を利用します。（利用する場合は□にチェック、利用しない場合は下記の欄を記入。）"]
[null,null,null,"注）口座情報の反映には登録から数日を要します。また、受取代理人を指定する場合は、公金口座を利用できません。"]
[{"$nulls":9},"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},")"]
[]
[{"$nulls":20},"口座名義",null,null,"(",{"$nulls":8},")"]
[]
[]
[null,null,"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":7},"￥"]
[null,"健保組合処理欄"]
[null,null,"款　項　目",{"$nulls":14},"取　　得",{"$nulls":4},"　　　　　年　　　　　月　　　　　日　　"]
[]
[null,null,"支　給　決　定",{"$nulls":14},"喪　　失",{"$nulls":4},"　　　　　年　　　　　月　　　　　日　　"]
[null,null,"年　　月　　日"]
[null,null,"支　　　　　払"]
[null,null,"年　　月　　日",{"$nulls":24},"受  付  日  付  印"]
[null,null,"支給額計算"]
[]
[null,null,"備　　　　　　考"]