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[{"$nulls":40},"被保険者記入用"]
["傷病手当金請求書①　（第　　　回）"]
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[null,null,"氏名（請求者）",{"$nulls":15},"住　　　所",{"$nulls":4},"〒",null,null,null,"-"]
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[null,null,"病気やけがの為\n仕事を休んだ期間\n( 請 求 期 間 ）",{"$nulls":7},"年",null,null,"月",null,null,"日から"]
[{"$nulls":10},"年",null,null,"月",null,null,"日まで"]
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[null,null,"傷  病  名",{"$nulls":15},"生年月日",{"$nulls":4},"　昭和　・　平成",{"$nulls":5},"年",null,null,null,"月",null,null,null,"日生"]
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[null,null,"発病または\n\n負傷の原因",{"$nulls":5},"（いつ）",{"$nulls":10},"午前",null,null,null,"時頃",null,"第三者行為によるものですか"]
[{"$nulls":10},"年",null,"月",null,"日（",null,null,"曜日）",null,"午後",{"$nulls":6},"１．はい",null,null,null,"２．いいえ"]
[{"$nulls":8},"（どこで）　自宅　・　職場　・　通勤中",{"$nulls":16},"「1.はい」の場合は「第三者行為による傷病届」を添付"]
[{"$nulls":8},"その他（",{"$nulls":15},"）","老齢・退職を事由とする公的年金の受給はありますか"]
[{"$nulls":8},"（何をしていて・どうした）",{"$nulls":16},"（例：老齢厚生年金）"]
[{"$nulls":26},"１．ある",null,null,null,"２．ない",{"$nulls":4},"３．手続中"]
[{"$nulls":25},"障害厚生年金・障害手当金の受給はありますか"]
[{"$nulls":26},"１．ある",null,null,null,"２．ない",{"$nulls":4},"３．手続中"]
[null,null,"被保険者\n銀行口座",{"$nulls":9},"銀　　行",{"$nulls":9},"本　　店",null,null,"労災保険から休業補償給付を受けていますか。（又は、"]
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[{"$nulls":12},"金　　庫",{"$nulls":9},"支　　店",null,null,"過去に受けたことがありますか。）"]
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[{"$nulls":12},"農　　協",{"$nulls":9},"出 張 所",null,null,"１．ある　　２．ない　　３．手続中（　　　　　　労働基準監督署）"]
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[{"$nulls":4},"普通",null,null,"口座番号",{"$nulls":14},"（ フ リ ガ ナ ）"]
[{"$nulls":22},"口 座 名 義"]
[]
[{"$nulls":4},"□マイナポータル等で事前登録した公金口座を利用します。（利用する場合は□にチェック、利用しない場合は上記の欄を記入。）"]
[{"$nulls":4},"注）口座情報の反映には登録から数日を要します。"]
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["療養を担当した医師が証明する欄",null,"傷病名",{"$nulls":13},"発病又は負傷の日",{"$nulls":5},"　　　年　　　月　　　日",{"$nulls":5},"発病又は"]
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[null,null,"　傷病の主症状及び経過状況　（労務不能期間における症状、療養指導、",{"$nulls":19},"転　　帰",null,null,null,"治癒　　・　　継続　　・　　中止　　・　　転医"]
[null,null,"　手術をした場合は名称と年月日など、できるだけ詳しく記入してください）"]
[{"$nulls":22},"この欄に記入したことは、事実に相違ない事を証明します。"]
[]
[{"$nulls":22},"　  　　　　年　　　　月　　　　日"]
[]
[{"$nulls":22},"　医療機関"]
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[{"$nulls":22},"　所 在 地"]
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[{"$nulls":22},"　名　　 称"]
[null,null,"　今後、労務不能と認められる期間及び意見"]
[{"$nulls":22},"　医師氏名"]
[]
[{"$nulls":22},"　電話番号"]
[]
[null,null,"※ご記入いただいた内容を訂正する場合は、訂正箇所を二重線で抹消し、正しい内容と証明者の氏名（サイン）をご記入ください。"]
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["健康保険組合処理欄"]
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[{"$nulls":29},"標準報酬月額"]
[{"$nulls":6},"（",{"$nulls":11},"）",{"$nulls":21},"千円"]
[null,null,"支給額計算"]
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[{"$nulls":8},3,{"$nulls":23},"□　事業主証明用に記入"]
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[{"$nulls":33},"受付日付印"]
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["請求時には、傷病手当金請求書②（事業主証明用）を同時にご提出ください。（任意継続被保険者、資格喪失後の給付の場合は提出不要）"]
["中部アイティ産業健康保険組合",{"$nulls":39},"2024年12月更新"]