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[null,null,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,"昭和\n平成\n令和",null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,"支払決議書"]
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[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,"喪失\n年月日",null,"令和",null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
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[null,null,null,null,null,"法定給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,null,"支給期間",null,null,null,"令和",null,"年",null,"月",null,null,"日",null,null,"日間"]
[]
[]
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[null,null,null,null,null,"付加給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,null,null,null,null,null,"令和",null,"年",null,"月",null,null,"日"]
[]
[]
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[null,null,null,null,null,"※備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"合計\n金額",null,"円"]
[]
[]
[]
[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,"小児　　弱視",null,"前回　　　　　　　　　年　　　月　　　日　更新　"]
[]
[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,"□","５歳未満（1年以上）"]
[]
[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,"□","５歳以上９歳未満（2年以上）"]
[]
[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,"弾性　　着衣",null,"前回　　　　　　　　　年　　　月　　　日　購入"]
[]
[null,null,null,null,null," 区分：   本人   ・   六歳   ・   家族   ・    高一   ・    高７ （高7被扶養者：□被保険者70歳未満の場合高一該当）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（※前回より6ヵ月経過後）"]
[]
[]
[null,null,null,null,null,"被保険者",null,null,null,null,"療養費支給申請書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(","第",null,null,"回",")"]
[]
[]
[null,null,null,null,null,"家　族"]
[]
[]
[null,null,null,null,null,"※　「被保険者」　「家族」　は該当する方を○で囲んで下さい。"]
[null,null,null,null,"被保険者が記入するところ",null,"被保険者証の記号番号",null,null,null,null,null,null,null,null,null,null,null,"事業所\nの名称\nTEL"]
[]
[null,null,null,null,null,null,"記号",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,null,null,null,null,null,null,"（",null,null,null,null,"）"]
[]
[null,null,null,null,null,null,"対象者",null,null,null,null,"氏名","ﾌﾘｶﾞﾅ",null,null,null,null,null,null,null,null,null,null,"対象者の\n生年月日",null,null,"昭和",null,null,null,null,null,null,null,"被保険者\nとの続柄"]
[]
[]
[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,"平成",null,null,"年",null,"月",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,null,"令和"]
[]
[null,null,null,null,null,null,"申請理由\n療養の給付を\n受けることが\nできなかった\n理由を選んで\n□にチェック\nしてください。",null,null,null,"①",null,null,null,"医師の指示により、治療用装具を作成・購入したため。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※装具の装着が必要である旨を示した「医師の意見書」と「装具の領収書」原本を添付"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　靴型装具の申請は、上記に加えて「靴の全体像が分かる写真」を添付"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※9歳未満の弱視斜視等の治療用眼鏡の申請には「指示書」と「眼鏡の領収書」原本を添付"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※弾性着衣等を購入した際の申請には「弾性着衣等装着指示書」と「弾性着衣等の領収書」原本を添付"]
[]
[null,null,null,null,null,null,null,null,null,null,"②",null,null,null,"健康保険の手続き中で、医療機関に保険証を提示できなかったため。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※医療機関が作成した「診療報酬明細書」と「領収書」原本を添付"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"③",null,null,null,"当健康保険組合資格取得後または認定後に、前保険者の保険証を使用したため。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※前保険者から送付された「診療報酬明細書」と前保険者に支払った「領収書」原本を添付"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"④",null,null,null,"その他　詳細記入→【",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,"傷病名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発病または負傷\nの年月日",null,null,null,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,null,null,null,null,null,null,"（負傷の場合は",null,null,null,null,null,"時頃）"]
[]
[null,null,null,null,null,null,"発病又は負傷の原因",null,null,null,null,null,"※詳しくご記入ください。 負傷の場合は「負傷原因届」をご提出ください。"]
[]
[]
[]
[]
[null,null,null,null,null,null,"傷病の経過"]
[]
[]
[]
[null,null,null,null,null,null,"診察を受けた\n医療機関の",null,null,null,null,null,"名　　　　　　　　称",null,null,null,null,null,null,null,null,"所在地",null,null,null,null,null,null,null,null,null,null,null,"診察した医師の氏名"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"上記の申請理由が\n②③の場合",null,null,null,null,null,"診察期間",null,null,null,null,"自","令和",null,null,null,null,null,null,null,"～","至","令和"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,"年",null,"月",null,"日",null,null,"日間"]
[]
[]
[null,null,null,null,null,null,"上記の申請理由が\n①の場合",null,null,null,null,null,"装具装着日",null,null,null,null,"令和",null,null,null,null,null,null,null,null,"装具購入金額"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,"円"]
[]
[]
[null,null,null,null,null,null,"第三者の行為に\nよって負傷した\nものであるか",null,null,null,null,null,"ある",null,null,"第三者の行為によって\n負傷したとき\nその事実の届出の有無",null,null,null,null,null,"第三者の方の氏名と住所と連絡先　　（不明のときはその旨を記入してください。）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,"連絡先"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"ない"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,null,null,null,null,null,null,null,"不明理由"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,"・",null,"無"]
[]
[null,null,null,null,null,null,"　　　上記のとおり申請します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,null,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,null,null,"電話番号",null,null,null,null,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,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,null,"生年月日",null,null,null,"昭和　・　平成",null,null,null,null,"年",null,"月",null,"日"]
[]
[]
[]
[null,null,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,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,null,null,"被保険者の氏名"]
[]
[]
[null,null,null,null,null,null,"※退職後等の申請で、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,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,null,"決裁日付印",null,null,null,null,null,null,"受付日付印"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[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,"　"]