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[{"$nulls":21},"常務理事",null,null,"事 務 長",null,null,"係",null,null,"担 当 者"]
[]
[]
[null,"定 期 健 康 診 断 補 助 支 給 申 請 書"]
[]
[null,"★健診の補助を申請される方には、健診結果のコピーを添付していただきます。頂いた健診データは、疾病統計等の作成・保健指導の資料等に使用されます。"]
[null,"健康保険\n記号",{"$nulls":5},"申請対象\n健診月",null,null,"令和",null,null,"年",null,"月","健診分",null,null,"申請\n年月日",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[null,"受　診　者　状　況",null,null,"定　期　健　診",{"$nulls":8},"申     請     人     数",{"$nulls":10},"補助申請額計"]
[{"$nulls":5},"一般健診",{"$nulls":8},"本　　人",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":14},"家族",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":5},"生活習慣病健診\n（３５歳以上）",{"$nulls":8},"本　　人",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":14},"家　　族",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":5},"人間ドック\n（３５歳以上）",{"$nulls":8},"本　　人",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":14},"家　　族",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":5},"子宮がん検診",{"$nulls":8},"本　　人",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":14},"家　　族",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":5},"乳がん検診",{"$nulls":8},"本　　人",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":14},"家　　族",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":5},"ＰＳＡ検査\n（４０歳以上）",{"$nulls":8},"本　　人",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":14},"家　　族",{"$nulls":7},"名",{"$nulls":8},"円"]
[{"$nulls":4},"申　　　請　　　額　　　合　　　計",{"$nulls":26},"円"]
[null,"上記のとおり申請します。"]
[null,"事業主が領収書を確認した場合には領収書の提出が不要となります。"]
[null,"確認された場合は、下のチェックボックスにチェックをいれてください。"]
[null,"□",null,"領収書の内容を確認しました。"]
[null,"事業所所在地 "]
[null,"事業所名称　　"]
[null,"事業主名　　　　"]
[null,"電話番号"]
[null,"ご担当者名"]
[null,"　　　補助額は事業所の保険料振替口座にお振込いたします。"]
[]
[null,"中部アイティ産業健康保険組合理事長　殿"]
[]
[null,"※申請内容を確認する必要があるときは、領収書等の提出を求めることがありますので、"]
[null,"申請日から2年間保存しておいてください。"]
[]
[null,"【補助対象受診期間】　",{"$nulls":25},"受 付 年 月 日"]
[null,"４０歳以上：４月～１２月　３９歳以下：４月～１月"]
[]
[null,"【申請期間】　"]
[null,"受診月",{"$nulls":6},"申請期間"]
[null,"4月～6月受診",{"$nulls":6},"4月～8月20日まで"]
[null,"7月～9月受診",{"$nulls":6},"7月～11月20日まで"]
[null,"10月～12月受診",{"$nulls":6},"10月～1月20日まで（40歳以上）",{"$nulls":14},"健 康 保 険 組 合 記 入 欄"]
[{"$nulls":8},"10月～2月20日まで（39歳以下）",{"$nulls":14},"振込予定日",{"$nulls":4},"令和　　　年　　　月　　　日"]
[null,"1月受診（39歳以下のみ）",{"$nulls":6},"3月15日まで",{"$nulls":14},"特定健診対象",{"$nulls":4},"名　"]
[null,"◎申請可能期間の締切り日が土日祝日の場合は、前日が締切り日となります。"]
[]
[null,"【添付書類】 "]
[null,"申請者一覧表・健診結果（写）・※ＸＭＬデータ(40歳以上）",{"$nulls":34},"2024年10月更新"]
[null,"※ＸＭＬデータが提出できない場合は質問票をご提出ください。",{"$nulls":34},"　中部アイティ産業健康保険組合"]
[]
[]
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[]
[null,null,"　 　　　　　　　"]