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{"sheet":"療養費","index":0,"n_rows":42,"n_cols":17,"rows_kept":42,"cut":false,"hidden":false,"merged":[[36,3,37,10],[36,11,37,16],[38,3,38,5],[34,2,34,5],[34,6,34,16],[34,1,38,1],[35,2,38,2],[35,3,35,6],[26,6,27,9],[26,10,26,16],[27,10,27,16],[28,6,30,9],[28,10,28,16],[29,10,30,10],[29,11,30,11],[29,13,30,13],[29,14,30,14],[29,15,30,15],[29,16,30,16],[28,1,30,5],[35,11,35,13],[29,12,30,12],[19,4,19,13],[20,4,20,13],[19,14,20,16],[21,1,22,3],[21,4,22,16],[20,1,20,3],[17,11,17,16],[19,1,19,3],[23,1,25,5],[26,1,27,5],[23,16,25,16],[16,1,16,4],[12,1,12,4],[17,1,17,2],[17,3,17,8],[17,9,17,10],[13,10,15,12],[13,13,15,16],[13,1,14,2],[15,1,15,2],[15,3,15,5],[15,6,15,7],[13,3,14,9],[15,8,15,9],[4,13,5,14],[4,15,5,16],[7,1,8,16],[9,1,11,1],[9,2,11,3],[9,4,11,16],[1,9,1,10],[2,9,2,10],[3,9,3,10],[4,9,5,10],[4,11,5,12]]}
[]
[null,null,null,null,null,null,null,null,null,"決定額"]
[null,null,null,null,null,null,null,null,null,"一部負担額"]
[null,null,null,null,null,null,null,null,null,"支給額"]
[null,null,null,null,null,null,null,null,null,"公費負担",null,"福",null,"障"]
[]
[null,"支給申請書受理番号："]
[null,"国民健康保険療養費支給申請書"]
[]
[null,"申請者\n(世帯主)","住  所\n氏  名"]
[]
[]
[null,"申請者の個人番号"]
[null,"被保険者の\n記号番号",null,null,null,null,null,null,null,null,"療養を受けた\n被保険者氏名"]
[]
[null,"世帯番号",null,null,null,null,"受診者宛名番号"]
[null,"被保険者の個人番号"]
[null,"生年月日",null," S・H・R　　　年　　　月　　　　日",null,null,null,null,null,"性  別",null,"男　・　女　・　その他"]
[]
[null,"傷病名"]
[null,"発病負傷年月日",null,null,"年　　　　月　　　　日"]
[null,"療養期間\n（調剤・施術）",null,null,"　　年　　　　月　　　　日から　　　　年　　　　月　　　　日まで　　　日間"]
[]
[null,"診療薬事の支給又は手当を受けた\n病院・診療所・薬局\nその他の者の名称及び所在地"]
[]
[]
[null,"療養費の支給申請をした理由\n<被保険者証で治療を受けられなかった具体的な理由>",null,null,null,null,null,null,null,null,"診療調剤又は手当に従事した医師、\n歯科医師、薬剤師その他の者の氏名"]
[]
[null,"発症又は不詳の理由",null,null,null,null,"1：第三者行為（交通事故等）\n2：業務上の災害（通勤災害） 3：その他（自損事故・疾病等）",null,null,null,"療養に要した費用"]
[null,null,null,null,null,null,null,null,null,null,"百万","十万","万","千","百","十","円"]
[]
[]
[null,"上記のとおり療養に要した費用に関する証拠書類を添えて申請します。"]
[null,null,"申請年月日　　　　　年　　　　月　　　　日　　下記口座にお振込み下さい。"]
[null,"振込先","口座名義人（カナ）"]
[null,null,"振込先金融機関","銀行コード",null,null,null,null,null,null,null,"支店コード"]
[null,null,null,"銀行\n信用金庫\n信用組合\n協同組合",null,null,null,null,null,null,null,"支店"]
[]
[null,null,null,"口座番号\n（右詰め）",null,null,null,null,null,null,null,null,null,"預金\n種別","普通","当座","貯蓄"]
[]
[null,"（世帯主と預金名義人が違う場合は、この欄に署名捺印してください。）"]
[null,"上記名義人口座への振込を了承します。　　世帯主氏名　　　　　　　　　　　　　　　　　　印"]