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{"sheet":"高額資金貸付申込書 5.4","index":0,"n_rows":49,"n_cols":16,"rows_kept":49,"cut":false,"hidden":false,"merged":[[48,13,48,15],[22,1,25,1],[22,3,25,3],[22,8,25,8],[22,10,25,10],[22,12,23,12],[24,11,25,15],[22,9,25,9],[22,13,23,15],[17,7,17,15],[18,7,18,15],[20,0,20,16],[21,2,21,5],[21,7,21,9],[21,10,21,15],[22,4,25,7],[27,0,27,1],[42,0,46,1],[42,3,42,11],[42,12,42,13],[42,14,42,16],[43,3,43,11],[44,2,46,11],[40,0,40,6],[40,12,40,13],[40,14,40,16],[41,0,41,2],[41,3,41,11],[41,12,41,13],[41,14,41,16],[40,7,40,11],[32,0,32,1],[39,0,39,16],[11,2,12,2],[12,12,13,12],[13,4,13,11],[11,4,12,11],[12,13,13,15],[19,4,19,11],[19,13,19,15],[26,0,26,16],[9,13,10,14],[14,0,14,16],[15,4,15,12],[15,14,15,15],[16,4,16,15],[17,2,18,2],[11,13,11,15],[22,11,23,11],[22,2,25,2],[0,13,0,16],[2,0,2,16],[4,0,4,16],[9,1,10,1],[9,2,10,2],[9,3,10,3],[9,4,10,11],[9,12,10,12]],"flags":["formulas_cached_only"]}
[{"$nulls":12},"申込日","平成　　　年　　　月　　　日"]
[null,null,"中部アイティ産業健康保険組合理事長　　殿"]
["高額医療費資金貸付申込書"]
[]
["　高額医療費資金貸付規程に従い、下記の通り高額医療資金を借用いたしたく"]
[null,null,"　　 申込みます"]
[]
[null,"（申込者記入欄）"]
[]
[null,null,"事業所",{"$nulls":9},"保　険　証\n記号･番号","-",null,"標準報酬月額"]
[{"$nulls":15},"千円"]
[null,null,"住所",{"$nulls":9},"ﾌ ﾘ ｶﾞ ﾅ"]
[{"$nulls":12},"氏　　名"]
[null,null,"電話 ",null,"　 　　-  　　　　　       -   　　"]
[]
[null,null,"療養者名",{"$nulls":10},"続柄"]
[null,null,"傷病名"]
[null,null,"医療機関",null,null,"名称"]
[{"$nulls":5},"所在地"]
[null,null,"医療機関から\nの請求金額",null,"円",{"$nulls":7},"支払期限"," 平成　　　年　　　月　　　日"]
[]
[null,null,"貸付申込額",{"$nulls":4},"円",null,null,"（注）貸付申込額は高額医療費に該当する\n　　　 額の８０／１００を限度とします。"]
[null,null,"振込先",{"$nulls":5},"銀行\n金庫\n農協",null,"本店\n支店\n出張所","普通","口座番号","(                            )"]
[]
[{"$nulls":11},"口座名義  (                                           )"]
[]
[]
["※",null,"添付書類"]
[null,null,"１．医療機関からの医療に要した費用の内訳が記載された請求書又は領収書。"]
[null,null,"２．申込者が市町村税の非課税者又は生活保護法の適用を受けている場合は、該当すること"]
[null,null,"　　を証明する書類。"]
[]
["※",null,"この申込書は、医療機関ごと、暦月ごとに別用紙としてください。"]
[null,null,"貸付限度額算出方法（１，０００円未満切捨て）"]
[null,null,"〔保険適用分自己負担額－｛80,100円+(総医療費-267,000円)×１％｝〕×８０％=貸付限度額"]
[null,null,"標準報酬月額５３万円以上の方"]
[null,null,"〔保険適用分自己負担額－｛167,400円+(総医療費-558,000円)×１％｝〕×８０％=貸付限度額"]
[]
[null,null,"（健保組合記入欄）"]
["高 額 療 養 費 資 金 貸 付 可 否 決 定 伺"]
["平成　　　年　　　月　　　日",{"$nulls":6},"貸付　　　可　･　否",{"$nulls":4},"高 額 療 養 費\n支 給 見 込 額",null,"円"]
["貸  付  金  額",null,null,"                                             円",{"$nulls":8},"貸 付 年 月 日",null,"平成　　　年　　　月　　　日"]
["算出基礎",null,"診療総点数","　　　　　　　　　　  　　　　　　　　点\n（薬）　　　　　　　　　  　　　　　　円",{"$nulls":8},"返　 　済 　　日",null,"平成　　　年　　　月　　　日"]
[null,null,"公費対象点数","                                             点"]
[]
[]
[]
[]
[{"$nulls":13},"2023年4月更新"]

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["常務理事","事 務 長","担　　当"]