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[{"$nulls":20},"常務理事",null,null,"事 務 長",null,null,"係",null,null,"担 当 者"]
[null,"任意継続被保険者様用"]
[]
["定 期 健 康 診 断 補 助 支 給 申 請 書"]
[]
["★健診の補助を申請される方には、健診結果のコピーを添付していただきます。頂いた健診データは、疾病統計等の作成・保健指導の資料等に使用されます。"]
["健康保険記号番号",{"$nulls":9},"申 請 対 象 健 診 月",{"$nulls":10},"申　請　年　月　日"]
[8888,null,null,null,"‐",{"$nulls":5},"令和",null,null,null,"年",null,null,"月","健診分",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["住　　　所",null,null,null,"〒",{"$nulls":20},"電 話 番 号"]
["氏　　　名"]
["受診者状況",null,"定　期　健　診",{"$nulls":5},"申請人数\nＡ",{"$nulls":4},"補助上限額/1名\nＢ",{"$nulls":5},"補助額-実費　Ｃ\n実費が補助額より\n下回った場合　",{"$nulls":5},"合　　　計\n（Ａ×Ｂ-Ｃ）"]
[]
[null,null,"一般健診",{"$nulls":5},"本人",null,null,null,"名",7000,{"$nulls":10},"円",{"$nulls":6},"円"]
[{"$nulls":8},"家族",null,null,null,"名",7000,{"$nulls":10},"円",{"$nulls":6},"円"]
[null,null,"生活習慣病健診\n（35歳以上）",{"$nulls":5},"本人",null,null,null,"名",15000,{"$nulls":10},"円",{"$nulls":6},"円"]
[{"$nulls":8},"家族",null,null,null,"名",15000,{"$nulls":10},"円",{"$nulls":6},"円"]
[null,null,"人間ドック\n（35歳以上）",{"$nulls":5},"本人",null,null,null,"名",25000,{"$nulls":10},"円",{"$nulls":6},"円"]
[{"$nulls":8},"家族",null,null,null,"名",25000,{"$nulls":10},"円",{"$nulls":6},"円"]
[null,null,"子宮がん検診",{"$nulls":5},"本人",null,null,null,"名",4000,{"$nulls":10},"円",{"$nulls":6},"円"]
[{"$nulls":8},"家族",null,null,null,"名",4000,{"$nulls":10},"円",{"$nulls":6},"円"]
[null,null,"乳がん検診",{"$nulls":5},"本人",null,null,null,"名",4000,{"$nulls":10},"円",{"$nulls":6},"円"]
[{"$nulls":8},"家族",null,null,null,"名",4000,{"$nulls":10},"円",{"$nulls":6},"円"]
[null,null,"PSA検査\n（40歳以上）",{"$nulls":5},"本人",null,null,null,"名",1800,{"$nulls":10},"円",{"$nulls":6},"円"]
[{"$nulls":8},"家族",null,null,null,"名",1800,{"$nulls":10},"円",{"$nulls":6},"円"]
[null,null,"申　　　請　　　額　　　合　　　計",{"$nulls":28},"円"]
[]
["被保険者銀行口座",{"$nulls":7},"銀行\n金庫\n農協",{"$nulls":7},"本店\n支店\n出張所",null,null,"普通",null,"口座番号",null,null,null,"（",{"$nulls":5},"）"]
[]
[{"$nulls":19},"ﾌﾘｶﾞﾅ",null,null,null,"（",{"$nulls":7},"）"]
[{"$nulls":19},"口座名義"]
[]
["中部アイティ産業健康保険組合理事長　殿",{"$nulls":24},"受 付 年 月 日"]
[]
[null,"健 康 保 険 組 合 記 入 欄"]
[null,"振込予定日",null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,"【補助対象受診期間】　40歳以上：4月～12月　39歳以下：4月～1月"]
[]
[null,"【申請期間】　",null,null,null,"受診日",{"$nulls":8},"申請期間"]
[{"$nulls":5},"4月～6月受診",{"$nulls":8},"4月～8月20日締切り"]
[{"$nulls":5},"7月～9月受診",{"$nulls":8},"7月～11月20日締切り"]
[{"$nulls":5},"10月～12月受診",{"$nulls":8},"10月～1月20日締切り（40歳以上）"]
[{"$nulls":14},"10月～2月20日締切り（39歳以下）"]
[{"$nulls":5},"1月受診（39歳以下のみ）",{"$nulls":8},"3月15日締切り"]
[{"$nulls":5},"◎申請可能期間の締切り日が土日祝日の場合は、前営業日が締切り日となります。"]
[null,"【添付書類】　申請者一覧表・健診結果（写）・※ＸＭＬデータ(40歳以上）・領収書（原本）"]
[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":29},"2023年4月更新"]