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["定期健康診断補助支給申請者一覧"]
[null,"記号・番号","８８８８－"]
[null,"氏　　　名"]
[{"$nulls":5},"注1：年度末（３月３１日）の年齢をご記入ください。",{"$nulls":4},"※2添付"]
[{"$nulls":10},"確認チェック"]
["健診機関",null,"被保険者\n番号","受診者名","本・家","注1","健診種類※1","受診日","受診金額","健保\n補助額","質問票","データ"]
[{"$nulls":5},"年齢"]
["記入例","○○○○",58,"健保　太郎","本",40,"人間ドック",710,38000,25000,null,"○"]
[null,"○○○○",58,"健保　太郎","本",40,"前立腺癌(PSA)",710,2000,1800]
[null,"　　　　　　　注2：前立腺癌(PSA)の補助は、「人間ドック」健診項目に含まれてる場合は申請できません。"]
[null,"◇◇◇◇◇",102,"健康　花子","家",45,"生活習慣病健診",715,21000,15000,"○"]
[null,"◇◇◇◇◇",102,"健康　花子","家",45,"子宮がん検診",715,3500,3500]
[null,"◇◇◇◇◇",102,"健康　花子","家",45,"乳がん検診",715,7500,4000]
{"$rows_empty":20}
[{"$nulls":7},"計"]
["※1　一般健診・生活習慣病・人間ドック・乳がん検診・子宮がん検診・前立腺がん（ＰＳＡ）"]
["※2　４０歳以上の方は、質問票またはＸＭＬデータを必ず添付してください。"]