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["出産手当金請求書（産前･産後）"]
["被 保 険 者 記 入 欄","被保険者等\n記号・番号",null,null,"記号",{"$nulls":5},"番号",{"$nulls":5},"記号番号が分からない場合はマイナンバーを記入してください。"]
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[null,"被保険者氏名"]
[{"$nulls":16},"分娩予定年月日",{"$nulls":7},"年",null,null,"月",null,null,"日"]
[null,"住　　　所",null,null,"〒",null,null,"－"]
[{"$nulls":16},"実分娩年月日",{"$nulls":7},"年",null,null,"月",null,null,"日"]
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[null,"電話番号",null,null,"（",null,null,null,"）",null,null,null,"-",null,null,null,"分娩のため会社を\n休んだ期間",{"$nulls":4},"自",null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":21},"至",null,null,"年",null,null,"月",null,null,"日"]
[null,"被保険者\n銀行口座",null,"□マイナポータル等で事前登録した公金口座を利用します。（利用する場合は□にチェック、利用しない場合は下記の欄を記入。）"]
[null,null,null,"注）口座情報の反映には登録から数日を要します。"]
[{"$nulls":5},"銀　　　行\n金　　　庫\n農　　　協",{"$nulls":7},"本　　店\n支　　店\n出 張 所 ",null,null,"普通",null,"口座番号"]
[null,null,null,"（ フ リ ガ ナ ）"]
[null,null,null,"口 座 名 義 "]
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["事　 業 　主　 証 　明 　欄",null,null,"産前４２日間・産後５６日間についてご記入ください。 　　  産休･･･○　　出勤・・・△　　　有給・・・/　　　公休・・・×"]
[null,"　　　年　　　月",null,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"]
[null,"　　　年　　　月",null,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"]
[null,"　　　年　　　月",null,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"]
[null,"　　　年　　　月",null,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"]
[null,null,null,"*上記期間の給与支払状況について、いずれかに○をつけてください",{"$nulls":14},"　特記事項"]
[null,null,"　1.　全額支給した\n　2.　一部支給した\n　3.　支給しない",null,null,null,"１．２．の場合は支給状況を\n下欄に記入してください"]
[{"$nulls":12},"給与締切日",{"$nulls":4},"日",{"$nulls":16},"　　"]
[{"$nulls":12},"給与支払日",{"$nulls":4},"日"]
[null,"計算期日",null,null,"支払\n基礎\n日数",null,"基本給",null,null,"　　　手当",null,null,"　　　手当",null,null,"合　　計",null,null,"　この欄に記入したことは事実に相違ありません。"]
[{"$nulls":6},"1ヶ月",null,null,"1ヶ月",null,null,"1ヶ月"]
[{"$nulls":8},"円",null,null,"円",null,null,"円",{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
[null,"　/  　～　　 /",{"$nulls":16},"[事業所]"]
[null,"　/  　～　　 /",{"$nulls":16},"名称"]
[null,"　/  　～　　 /",{"$nulls":16},"所在地"]
[null,"　/  　～　　 /",{"$nulls":16},"事業主"]
[null,"給与の種類",null,null,"月給　・　日給月給　・　日給　・　時給　・　その他（　　　　　　　）"]
[null,"※ご記入いただいた内容を訂正する場合は、訂正箇所を二重線で抹消し、正しい内容と証明者の氏名（サイン）をご記入ください。"]
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["病院が証明する欄","分 娩 予 定 年 月 日",{"$nulls":5},"     　　　　年　　　　月　　　　日",{"$nulls":11},"出生児の数"]
[null,"実  分  娩  年  月  日",{"$nulls":5},"     　　　　年　　　　月　　　　日",{"$nulls":11},"単胎（1名）",{"$nulls":4},"・","多胎（　　　名）"]
[null,"生  産  ・ 死  産 の 別",{"$nulls":5},"生産",null,null,"・","死産",null,"（妊娠",{"$nulls":4},"ヶ月）"]
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[null,null,null,"上記の通り相違ない事を証明する。",{"$nulls":8},"医療施設名称"]
[]
[{"$nulls":4},"年",null,"月",null,"日",null,null,null,"医　　師　　名"]
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[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。"]
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["健　保　組　合　処　理　欄","支 給 額",null,null,"円",{"$nulls":6},"支 給 日",null,null,null,"       年　　  　月　 　　日",{"$nulls":6},"常務理事",null,null,"事務長",null,"担当",null,"確認"]
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[null,"支給期間",null,null,"産前  　　 年　　月　　日 ～ 　　年　　月　　日　　　日間"]
[{"$nulls":4},"延長  　　 年　　月　　日 ～ 　　年　　月　　日　　　日間",{"$nulls":14},"計",null,"日間","資格","取得",null,null,"年",null,"月",null,"日"]
[{"$nulls":4},"産後  　　 年　　月　　日 ～ 　　年　　月　　日　　　日間",{"$nulls":18},"喪失",null,null,"年",null,"月",null,"日"]
[null,"不支給期間と\nそ の 理 由",{"$nulls":17},"計",null,"日間","標準報酬\n月　　額",{"$nulls":6},"千円"]
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[null,"支給額計算"]
[{"$nulls":25},"受付日付印"]
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["中部アイティ産業健康保険組合",{"$nulls":29},"2024年12月更新"]