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[{"$nulls":115},"別添１（様式第６号）"]
[]
[]
[]
[{"$nulls":4},"療 養 費 支 給 申 請 書（　　年　　月分）（はり・きゅう用）"]
[]
[]
[]
[{"$nulls":80},"機関コード　　　　　　　　　　　　　　　　　"]
[]
[]
[]
[{"$nulls":4},"公費負担者番号",{"$nulls":75},"特記事項",{"$nulls":35},"2 本外",{"$nulls":19},"給付割合"]
[]
[{"$nulls":98},"1 社国",{"$nulls":8},"3 後高",{"$nulls":16},"8 高外一"]
[{"$nulls":116},"4 六外"]
[]
[{"$nulls":4},"公費受給者番号",{"$nulls":119},"0 高外7",{"$nulls":11},8,{"$nulls":5},9,{"$nulls":5},10]
[{"$nulls":98},"2 公費",{"$nulls":8},"4 退職",{"$nulls":8},"6 家外"]
[]
[]
[]
[{"$nulls":4},"区市町村番号"]
[{"$nulls":92},"種類",{"$nulls":9},"05 鍼灸"]
[]
[]
[]
[{"$nulls":4},"受給者番号",{"$nulls":74},"保 険 者 番 号"]
[]
[]
[]
[]
[]
[{"$nulls":4},"被保険者欄",{"$nulls":4},"○被保険者証等の記号番号",{"$nulls":36},"○発病又は負傷年月日",{"$nulls":28},"○傷病名、発症又は負傷の原因及びその経過"]
[]
[]
[]
[{"$nulls":46},"年　　月　　日 "]
[]
[]
[]
[]
[{"$nulls":9},"療 養 を\n受けた者\nの 氏 名",{"$nulls":18},"(ﾌﾘｶﾞﾅ)",{"$nulls":45},"続　柄",{"$nulls":12},"○業務上・外、第三者行為の有無"]
[]
[]
[]
[{"$nulls":68},"男・女",{"$nulls":18},"（　１．業務上　２．第三者行為　３．その他（　 　　　　　　　　　　））"]
[]
[]
[]
[]
[{"$nulls":87},"○施術した場所（入居施設や住所地特例等、保険証住所地と異なる場合に記載）"]
[]
[]
[]
[]
[{"$nulls":28},"明・大・昭・平・令　　年　　月　　日生"]
[]
[]
[]
[]
[{"$nulls":4},"施 　術 　内　 容　 欄",{"$nulls":4},"初 療 年 月 日",{"$nulls":32},"施　術　期　間",{"$nulls":63},"実日数",{"$nulls":11},"請 　求 　区 　分"]
[]
[]
[]
[]
[{"$nulls":9},"（　　）　　年　　月　　日",{"$nulls":32},"自・令和　 年　 月　 日～至・令和　 年　 月 　日",{"$nulls":63},"日",{"$nulls":11},"新　規　・　継　続"]
[]
[]
[]
[]
[{"$nulls":9},"　傷病名",{"$nulls":20},"１．神経痛",{"$nulls":18},"２．リウマチ",{"$nulls":24},"３．頸腕症候群",{"$nulls":21},"４．五十肩",{"$nulls":21},"転　　　　　帰"]
[]
[]
[]
[]
[{"$nulls":30},"５．腰痛症",{"$nulls":18},"６．頸椎捻挫後遺症",{"$nulls":24},"７．その他（　　　　　　　　　）",{"$nulls":43},"継続・治癒・中止・転医"]
[]
[]
[]
[]
[{"$nulls":9},"初検料（１はり　２きゅう　３はりきゅう併用）",{"$nulls":47},"円",{"$nulls":60},"摘　　　要"]
[]
[]
[]
[]
[{"$nulls":9},"施　術　料",{"$nulls":4},"はり・きゅう",{"$nulls":42},"施術の種類",{"$nulls":16},"１術　　　　　回",{"$nulls":22},"２術　　　　回"]
[]
[]
[]
[]
[{"$nulls":22},"　通所",{"$nulls":51},"円×",{"$nulls":19},"回＝",{"$nulls":19},"円"]
{"$rows_empty":7}
[{"$nulls":22},"　訪問施術料　１",{"$nulls":34},"円×　　　　回＝　　　　円"]
{"$rows_empty":7}
[{"$nulls":22},"　訪問施術料　２",{"$nulls":34},"円×　　　　回＝　　　　円"]
{"$rows_empty":7}
[{"$nulls":22},"　訪問施術料　３（３人～９人）",{"$nulls":34},"円×　　　　回＝　　　　円"]
{"$rows_empty":7}
[{"$nulls":22},"　訪問施術料　３（10人以上）",{"$nulls":34},"円×　　　　回＝　　　　円"]
{"$rows_empty":7}
[{"$nulls":14},"電療料（加算／　１電気針　２電気温灸器　３電気光線器具）",{"$nulls":42},"円×　　　　回＝　　　　円"]
[]
[]
[]
[]
[{"$nulls":14},"特 別 地 域（加 算）",{"$nulls":42},"円×　　　　回＝　　　　円"]
[]
[]
[]
[]
[{"$nulls":9},"　往　療　料",{"$nulls":47},"円×　　　　回＝　　　　円"]
[]
[]
[]
[]
[{"$nulls":9},"施術報告書交付料（前回支給：　年　月分）",{"$nulls":47},"円×　　　　回＝　　　　円"]
[]
[]
[]
[]
[{"$nulls":9},"合　　　　　　　　　　計",{"$nulls":47},"円"]
[]
[]
[]
[]
[{"$nulls":9},"一部負担金（１ 割 ・ ２ 割 ・ ３ 割）",{"$nulls":47},"円"]
[]
[]
[]
[]
[{"$nulls":9},"請　　　　 求 　　　　額",{"$nulls":47},"円"]
[]
[]
[]
[]
[{"$nulls":9},"施術日",{"$nulls":6},"訪問１①",{"$nulls":6},"月",{"$nulls":5},1,{"$nulls":3},2,{"$nulls":3},3,{"$nulls":3},4,{"$nulls":3},5,{"$nulls":3},6,{"$nulls":3},7,{"$nulls":3},8,{"$nulls":3},9,{"$nulls":3},10,{"$nulls":3},11,{"$nulls":3},12,{"$nulls":3},13,{"$nulls":3},14,{"$nulls":3},15,{"$nulls":3},16,{"$nulls":3},17,{"$nulls":3},18,{"$nulls":3},19,{"$nulls":3},20,{"$nulls":3},21,{"$nulls":3},22,{"$nulls":3},23,{"$nulls":3},24,{"$nulls":3},25,{"$nulls":3},26,{"$nulls":3},27,{"$nulls":3},28,{"$nulls":3},29,{"$nulls":3},30,{"$nulls":3},31]
[]
[]
[{"$nulls":9},"通所○",{"$nulls":6},"訪問２②"]
[]
[]
[{"$nulls":9},"往療◎",{"$nulls":6},"訪問３③"]
[]
[]
[{"$nulls":9},"○往療又は訪問の理由（　１．独歩による公共交通機関を使っての外出困難　２．認知症や視覚、内部、精神障害などにより独歩による外出困難　３．その他（　　   　　　  　　　　            　　　　　　　　　　　　　　　　）　）"]
[]
[]
[]
[{"$nulls":4},"施術証明欄",{"$nulls":7},"上記のとおり施術を行い、その費用を領収しました。",{"$nulls":71},"保健所登録区分",{"$nulls":21},"1.施術所所在地　2.出張専門施術者住所地"]
[]
[]
[]
[{"$nulls":67},"施術所",{"$nulls":27},"〒　　　－"]
[]
[]
[{"$nulls":12},"令和　　　年　　　月　　　日",{"$nulls":71},"所在地"]
[]
[]
[]
[{"$nulls":12},"登録記号番号",{"$nulls":71},"名　称"]
[]
[]
[]
[{"$nulls":67},"施術管理者",{"$nulls":16},"氏　名",{"$nulls":45},"電話"]
[]
[]
[]
[{"$nulls":4},"申請欄",{"$nulls":7},"上記の療養に要した費用に関して、療養費の支給を申請します。",{"$nulls":82},"〒　　　－"]
[]
[]
[]
[{"$nulls":12},"令和　　　年　　　月　　　日",{"$nulls":54},"申請者\n（被保険者）",{"$nulls":16},"住所"]
[]
[]
[]
[{"$nulls":12},"殿"]
[]
[]
[{"$nulls":84},"氏名",{"$nulls":45},"電話"]
[]
[]
[]
[{"$nulls":4},"支払機関欄",{"$nulls":5},"支払区分",{"$nulls":43},"預金の種類",{"$nulls":30},"金融機関名",{"$nulls":35},"銀行",{"$nulls":22},"本店"]
[]
[]
[{"$nulls":11},"1．",{"$nulls":3},"振込",{"$nulls":17},"2．",{"$nulls":3},"銀行送金",{"$nulls":17},"1.　普通",{"$nulls":14},"2.　当座",{"$nulls":50},"金庫",{"$nulls":22},"支店"]
[]
[]
[{"$nulls":11},"3．",{"$nulls":3},"郵便局送金",{"$nulls":17},"4．",{"$nulls":3},"当地払",{"$nulls":17},"3.　通知",{"$nulls":14},"4.　別段",{"$nulls":50},"農協",{"$nulls":22},"出張所"]
[]
[]
[{"$nulls":9},"口　座　名　義\nカタカナで記入",{"$nulls":56},"口座番号",{"$nulls":57},"郵便局"]
[]
[]
[]
[]
[{"$nulls":4},"同意記録",{"$nulls":4},"同意医師の氏名",{"$nulls":25},"住　　　　　所",{"$nulls":42},"同 意 年 月 日",{"$nulls":29},"傷　　病　　名",{"$nulls":26},"要加療期間"]
[]
[]
[]
[{"$nulls":78},"令和 　年　 月　 日"]
{"$rows_empty":10}
[{"$nulls":9},"本申請書に基づく給付金に関する受領を代理人に委任します。",{"$nulls":83},"令和　　年　　月　　日"]
[]
[]
[]
[{"$nulls":9},"申請者",{"$nulls":16},"住所",{"$nulls":54},"代理人",{"$nulls":16},"住所"]
{"$rows_empty":7}
[{"$nulls":9},"（被保険者）",{"$nulls":16},"氏名",{"$nulls":71},"氏名"]
{"$rows_empty":9}
[{"$nulls":4},"※　この給付金の受領の代理人への委任は、受領委任の取扱規程（平成30年6月12日保発0612第2号通知）に従い行われるものです。"]
[]
[]
[{"$nulls":4},"※　給付金に関する受領を代理人に委任する（申請者名義以外の口座に振込を希望される）場合に署名してください。"]
[]
[]
[{"$nulls":4},"※　ただし、当該患者より依頼を受けた場合や当該患者が記入することができないやむを得ない理由がある場合には、施術管理"]
[]
[]
[{"$nulls":4},"　者等が代理記入をし当該患者から押印を受けてください。"]