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[null,"協和キリン健康保険組合　宛"]
[null,"健康保険　　限度額適用・標準負担額減額認定申請書"]
[]
[]
[null,"下記のとおり健康保険限度額適用・標準負担額減額認定証の交付を申請します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[]
[null,"被保険者の情報","被保険者証の\n記号番号",null,null,null,null,"記号",null,null,null,"番号",null,null,null,null,null,"会社名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所属"]
[null,null,"従業員番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"メールアドレス"]
[null,null,"申請者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※申請書氏名は自署で記入してください。"]
[]
[null,null,"被保険者住所",null,null,null,null,"（〒",null,null,null,null,null,null,null,null,"）","日中連絡先（TEL）"]
[]
[]
[null,"減額対象者","氏　　名",null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,"生年月日",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,"療養予定期間",null,null,null,null,null,null,"年",null,null,"月",null,null,"日","～",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"長期入院",null,null,null,null,null,"該当",null,null,null,"非該当",null,null,null,null,"入院日数合計",null,null,null,null,null,null,null,"日間"]
[null,"長期入院に該当する場合に記入",1,"申請を行った月以前\n１年間の入院期間（日数）",null,null,null,null,null,null,null,"年",null,"月",null,"日から",null,null,null,"年",null,"月",null,"日まで",null,"日数",null,null,null,"日間"]
[]
[null,null,null,"入院をした\n保険医療機関等",null,null,null,null,null,"名称"]
[null,null,null,null,null,null,null,null,null,"所在地"]
[null,null,2,"申請を行った月以前\n１年間の入院期間（日数）",null,null,null,null,null,null,null,"年",null,"月",null,"日から",null,null,null,"年",null,"月",null,"日まで",null,"日数",null,null,null,"日間"]
[]
[null,null,null,"入院をした\n保険医療機関等",null,null,null,null,null,"名称"]
[null,null,null,null,null,null,null,null,null,"所在地"]
[null,null,3,"申請を行った月以前\n１年間の入院期間（日数）",null,null,null,null,null,null,null,"年",null,"月",null,"日から",null,null,null,"年",null,"月",null,"日まで",null,"日数",null,null,null,"日間"]
[]
[null,null,null,"入院をした\n保険医療機関等",null,null,null,null,null,"名称"]
[null,null,null,null,null,null,null,null,null,"所在地"]
[]
[null,"希望送付先",null,null,null,null,null,null,"職場",null,null,null,null,null,null,null,null,null,null,null,"被保険者の情報に記入した住所"]
[null,null,null,null,null,null,null,null,"その他　",null,"〔　　　実家　・　　　病院　〕",null,null,null,null,null,"※宛名（様方・気付）、部屋番号、病棟、病室番号等が必要な場合は\n   もれなくご記入ください。"]
[null,null,null,null,null,null,null,null,"住所",null,null,"（〒",null,null,null,null,null,"）","TEL："]
[]
[null,null,null,null,null,null,null,null,"宛名"]
[null,"■「被保険者」および「認定対象者」以外の方が申請する場合にご記入ください。"]
[null,"申請代行者欄","氏　　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者\nとの関係",null,null,null,null,"総務・人事担当者",null,null,null,null,null,"上長"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族",null,"（","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,"その他",null,"（","　",null,null,null,null,"）"]
[null,null,"日中連絡先（TEL）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請代行の\n理由",null,null,null,null,"被保険者本人が入院中のため"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他",null,"（",null,null,null,null,null,"）"]
[]
[null,"市区町村長証明欄"]
[null,null,"　当該被保険者（氏名　　　　　　　　　　　　　　　　　　）は（　　　　　　　　　　）年度の市区町村民税が課されないこと証明する。"]
[]
[null,null,null,"市区町村長名",null,null,null,null,null,null,null,null,null,null,null,null,"㊞"]
[]
[null,"※4月～7月診療分については、前年度の課税に関する証明を、8月から翌年3月診療分については、当年度の課税に関する証明が必要となります。"]
[null,"※認定証の有効期間は、発行月1日から最長で初めて到来する7月末日までとなります。"]
[null,"※（非）課税証明書（原本）を添付する場合は、「市区町村長証明欄」の証明は必要ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"《健保受付日付印》"]
[]
[null,"健保記入欄","常務理事",null,null,"事務長",null,null,"担当"]
[]
[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,"2023.3.1改訂"]