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[null,null,"国民健康保険高額療養費支給申請書"]
[]
[null,"（宛先）風間浦村長　殿",null,null,null,null,null,null,"　　　　　年　　　月　　　日","　　　年　　　月　　　日"]
[]
[null,"被保険者証の記号番号",null,null,null,null,null,null,"現役並・一般・Ⅱ・Ⅰ・\nア・イ・ウ・エ・オ"]
[null,"療養を受けた者の氏名"]
[null,"生年月日",null,"昭・平・令　　年　　月　　日",null,null,"昭・平・令　　年　　月　　日",null,null,"昭・平・令　　年　　月　　日"]
[null,"個人番号"]
[null,"続柄"]
[null,"第三者行為該当",null,"有　・　無",null,null,"有　・　無",null,null,"有　・　無"]
[]
[null,"傷病名"]
[null,"療養を受けた\n医療機関等の\n名称及び所在地","名称"]
[null,null,"所在地"]
[null,"病院等で療養を\n受けた期間",null,"年　　月　　日から\n年　　月　　日まで\n入院・通院　　　　日間",null,null,"年　　月　　日から\n年　　月　　日まで\n入院・通院　　　　日間",null,null,"年　　月　　日から\n年　　月　　日まで\n入院・通院　　　　日間"]
[]
[null,"病院等で支払った額",null,"円",null,null,"円",null,null,"円"]
[]
[null,"上記の通り申請します。"]
[null,"　　　　　　年　　月　　日",null,null,null,"<世帯主>","住　所"]
[null,null,null,null,null,null,"氏　名",null,null,null,null,"印"]
[null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,"電話番号",null,"（",null,"）"]
[]
[null,"支払方法","\n1.振込\n\n2.窓口\n"]
[null,null,null,null,null,"銀　　行","信用組合",null,null,"支　店 ・ 支　所"]
[null,null,null,null,null,"信用金庫","協同組合",null,null,"(　　　　　　)"]
[null,"口座番号"]
[null,"口座名義人(カナ)"]
[]
[null,"決裁","課　長",null,"副参事",null,"G　L",null,"課　員",null,"担　当"]