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["高額医療費資金貸借契約証書"]
[null,null,"　　　年　　　月　　　日"]
[]
["(甲)"]
[null,null," 　　　 岐阜県大垣市加賀野４丁目１番地の７"]
[]
[null,null,null,"  　　中部アイティ産業健康保険組合　理事長　　　",{"$nulls":7},"印"]
[]
[]
[null,null,"（申込者記入欄）"]
[]
[null,null,"事業所",{"$nulls":4},"健康保険証\n記 号・番 号",null,"　　　　　　　　－"]
["(乙)",null,"住所",{"$nulls":4},"氏　　　　名",null,"ﾌﾘｶﾞﾅ"]
[]
[null,null,"電話","　　－　　　　　　　－　　　　"]
[]
[null,null,"療養者名",{"$nulls":6},"続 柄"]
[null,null,"傷  病  名"]
[null,null,"医療機関","名　 称"]
[null,null,null,"所在地"]
[null,null,"医療機関か\nらの請求額","円",null,null,null,"支 払 期 限",null,"平成　　 　年　 　　月　 　　日"]
[]
[null,null,"貸　付　申　込　額",null,"円"]
[null,null,"振込先",null,"銀行\n金庫\n農協",null,"本店\n支店\n出張所","普通","口座番号       (　　　　　　　　　　　　　　　　　）"]
[]
[{"$nulls":7},"  口座名義     (　　　　　　　　　　　 　　　　　　　　　　）"]
[]
[null,null,"　医療機関からの請求書又は領収書を必ず添付のこと。その他高額医療費資金貸付規程による。"]
[]
[null,null,"（健康保険組合記入欄）"]
[null,null,"貸　付　決  定　額",null,"円"]
[]
[]
[null,null,"１．甲は乙に対して、高額医療費資金貸付規程に従い、上記の通り金額を貸与し乙はこれを受領した。"]
[null,null,"２．この契約を証するために証書１通を作成し、中部アイティ健康保険組合がこれを保有する。"]
[null,null,"３．当該貸付金が乙から甲へ返還された場合、甲はこの契約証書を乙に交付することにより領収証にかえる。"]
[]
[{"$nulls":10},"　 　領　　収　　印"]
[null,null,"返　済　日","平成　　　　年　　　　月　　　　日"]
[]
[]
[{"$nulls":10},"2023年4月更新"]

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["収入印紙"]
["1万円以下非課税"]
[10,"〃","200円"]
[50,"〃","400円"]
[100,"〃","1,000円"]
[500,"〃","2,000円"]