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[null,"はり・きゅう施術内容明細書（施術者記入）"]
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[null,"健康保険被保険者",{"$nulls":5},"記号",null,null,null,"番号",null,null,null,"被保険者氏名"]
[null,"証の記号と番号"]
[null,"初療年月日",{"$nulls":5},"　　　年　　　　月　　　　日",{"$nulls":7},"請求区分",{"$nulls":4},"新規 ・ 継続"]
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[null,"施術期間",{"$nulls":5},"自　・　　　　　　年　　　　　月　　　　　日",{"$nulls":14},"実日数",null,null,null,"　　　　　　　　日"]
[{"$nulls":7},"至　・　　　　　　年　　　　　月　　　　　日"]
[null,"傷病名"]
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[null,"初検料",null," 1 . はり\n 2 . きゅう\n 3 . はりきゅう併用",{"$nulls":4},"円",{"$nulls":13},"請求区分",null,null,null,"新規　・　継続"]
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[null,"施術料",null,"は　　り",{"$nulls":4},"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円",{"$nulls":13},"転帰",null,null,null,"継続・治癒・中止・転医"]
[]
[]
[null,null,null,"き　ゅ　う",{"$nulls":4},"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円",{"$nulls":13},"摘要\n"]
[]
[{"$nulls":22},"※往療を必要とした場合に記入"]
[null,null,null,"はり・きゅう併用",{"$nulls":4},"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円"]
[{"$nulls":22},"〔往療日〕　　　　・　　　・　　　・　　　日"]
[]
[null,null,null,"電療料"," 1.電気針\n 2.電気温灸器\n 3.電気光線器具",null,null,null,"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円",{"$nulls":13},"〔往療を必要とした理由〕"]
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[null,"往療料",null,"4㎞まで",{"$nulls":4},"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円"]
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[]
[null,null,null,"4㎞超",{"$nulls":4},"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円"]
[]
[]
[null,"施術報告書交付料\n（前回支給：　　年　　月分）",{"$nulls":6},"　　　　　　　　　円　×　　　　　　　回　＝　　　　　　　　　円"]
[]
[]
[null,"合計",{"$nulls":6},"円"]
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[null,"施術日\n通院○/往療◎",null,null,null,"月　",null,"1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31"]
[]
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[null,"施術証明欄",null,"上記の通り施術を行い、その費用を領収しました。",{"$nulls":17},"保健所登録区分",{"$nulls":4},"　1. 施術所所在地　\n　2. 出張専門施術所所在地"]
[null,null,null,"　　　　　　年　　　月　　　日"]
[]
[null,null,null,"はり師免許登録番号",{"$nulls":11},"所在地"]
[null,null,null,"（　　　　　　　　　　　　　　　　　　　　　）"]
[]
[{"$nulls":15},"施術所名"]
[null,null,null,"きゅう師免許登録番号"]
[null,null,null,"（　　　　　　　　　　　　　　　　　　　　　）"]
[{"$nulls":15},"施術者名"]
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[]
[{"$nulls":15},"電話番号"]
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[null,null,null,"※ご記入いただいた内容を訂正する場合は、訂正箇所を二重線で抹消し、正しい内容と証明者の氏名（サイン）をご記入ください。"]
[null,"同意記録",null,"同意医師の氏名",{"$nulls":5},"住所",{"$nulls":7},"同意年月日",{"$nulls":5},"傷病名",{"$nulls":4},"要加療期間"]
[]
[{"$nulls":17},"　　　　年　月　日"]
[]
[]
[]
[null,"（注意事項）"]
[null,"・「はり・きゅう施術内容明細書」は施術者が記入してください。"]
[null,"　別途施術内容について確認できる書類をご提出いただく場合には、「はり・きゅう施術内容明細書」の提出"]
[null,"　は不要です。"]
[null,"・往療がある場合には、摘要欄に記入し、往療料の計算が確認できる書類をご提出下さい。"]
[null,"・初療日から1年以上を経過して、月に16回以上の施術があった場合は、「１年以上・月１６回以上施術継続"]
[null,"　理由・状態記入書」をご提出下さい。"]
[]
[]
[{"$nulls":21},"中部アイティ産業健康保険組合"]