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[null,null,null,"常務理事",null,null,"事務局長",null,null,"事務局次長",null,null,"業務課長",null,null,"係長",null,null,"伺　年　月　日",null,null,null,null,null,null,"取得\n年月日",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"支払決議書"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"喪失\n年月日",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[]
[]
[null,null,null,null,"法定給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,null,null,null,"出産\n年月日",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[]
[]
[null,null,null,null,"付加給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,"出　生　児　の　数",null,null,null,null,null,null,"生産または死産の別"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　単胎 ・多胎（　　児）",null,null,null,null,null,null,"生産 ・死産（妊娠　　 週）"]
[]
[]
[]
[null,null,null,"医療機関からの請求額",null,null,null,null,null,null,"※備考"]
[]
[null,null,null,"￥"]
[]
[]
[]
[]
[null,null,null,null,"被保険者",null,null,null,null,"出産育児一時金等内払金･付加金支払依頼書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"直接支払制度を　　　利用された方"]
[]
[]
[null,null,null,null,"家　族"]
[]
[]
[]
[null,null,null,null,null,"被保険者証の記号番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所の名称"]
[]
[null,null,"被　保　険　者　が　記　入　す　る　と　こ　ろ"]
[null,null,null,null,"記号",null,null,null,null,null,null,null,"番号"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL",null,null,null,null,null,"（",null,null,null,"）"]
[]
[]
[null,null,null,null,"出産年月日",null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","出産児数",null,null,"死産児数",null,null,"妊娠経\n過期間",null,null,"妊　 娠",null,null,null,null,"ヶ月"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"人",null,null,"人",null,null,null,"在胎数週",null,null,null,null,"週"]
[]
[]
[]
[null,null,null,null,"出産した\n医療機関等",null,null,null,null,"名称"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"所在地",null,"〒",null,null,"―"]
[]
[]
[]
[]
[]
[null,null,null,null,"出産者",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者と出生児との関係",null,null,null,null,null,null,"出生児が被保険者の被扶養者であるかどうか",null,null,null,null,null,"1, ある"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"1被保険者",null,null,null,null,"2.被扶養者"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2, ない"]
[]
[]
[]
[null,null,null,null,"家族が出産した\nときはその方の",null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,"続柄",null,null,null,"生年\n月日",null,"昭和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"平成"]
[]
[]
[null,null,null,null,"　　　上記のとおり請求します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"請求年月日",null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[null,null,null,null,"川口工業健康保険組合理事長　殿"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"〒",null,null,null,"―",null,null,null,null,null,null,"電話番号",null,null,null,null,null,"（",null,null,null,"）"]
[]
[]
[null,null,null,null,null,"被保険者の住所"]
[]
[]
[]
[]
[]
[null,null,null,null,null,"被保険者の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,"昭和",null,"平成",null,null,"年",null,"月",null,"日"]
[]
[]
[]
[]
[null,null,null,null,"委任状",null,null,null,null,"本申請書の提出を事業主へ委任します。（委任する場合は☑）"]
[]
[]
[null,null,null,null,null,null,null,"事業主を代理人として健康保険組合より支給される本請求金額全額の受取り方の件を委任いたします。"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"被保険者の氏名"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"※退職後等の請求で、上記に委任しない場合は、川口工業健康保険組合にお申し出下さい。"]
[]
[]
[]
[]
[null,null,"社　　会　　保　　険　　労　　務　　士　　記　　入　　欄　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"決裁日付印",null,null,null,null,null,"受付日付印"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,"川口工業健康保険組合（2023.4）"]
[]
[]
[]
[]
[null,null,"※自動払いよりも早く支払いを希望する場合にご提出ください。"]
[]
[]
[null,null,"※内払金については、医療機関等が直接支払制度により請求した出産育児一時金等の代理"]
[]
[]
[null,null,"  受取額が５０万円(産科医療補償制度対象分娩でない場合は48.8万円)未満であるときに、"]
[]
[]
[null,null,"  差額支給を受けるためのものです。"]
[]
[]
[]
[]
[null,null,null,"添　付　書　類"]
[]
[]
[]
[]
[null,null,null,1,"医療機関等から交付を受けた「専用請求書の内容と相違ない旨を記載した領収・明細書」の写し"]
[]
[]
[null,null,null,null,"(産科医療補償制度対象分娩についてはスタンプが押されているもの)"]
[]
[]
[]
[null,null,null,2,"医療機関等との「直接支払制度合意文書」の写し"]
[]
[]
[null,null,null,null,"(直接支払制度を利用する旨及び請求先の保険者が当健保である旨を記載があるもの)"]