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[null,"申　請　欄"]
[null,null,null,null,null,"　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。"]
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[null,null,null,null,"（被保険者）",null,null,null,null,null,null,null,null,"氏名",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,"氏名",null,null,null,null,null,{"$f":"基本!C25","v":"会長　仲嶋　隆史"}]
[]
[]
[]
[]
[null,null,"※　この給付金の受療の代理人への委任は、受領委任の取扱規定（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。"]
[null,null,"※　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。"]
[null,null,"※　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、"]
[null,null,null,null," 施術管理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。"]

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{"sheet":"基本","index":2,"n_rows":29,"n_cols":14,"rows_kept":29,"cut":false,"hidden":false,"merged":[[7,2,7,4],[8,2,8,4],[9,2,9,4],[10,2,10,4],[14,1,15,1],[14,2,14,3],[14,4,14,5],[15,2,15,3],[15,4,15,5],[12,1,13,1],[5,8,5,9],[6,2,6,5],[3,1,3,5],[4,2,4,5],[5,3,5,5],[10,13,18,17],[12,2,12,3],[12,4,12,5],[13,2,13,3],[13,4,13,5],[28,2,28,5],[22,2,22,5],[23,2,23,5],[24,2,24,5],[25,2,25,5],[26,2,26,5],[27,2,27,5],[21,1,21,5],[16,1,16,3],[16,4,16,5],[17,1,17,3],[17,4,17,5],[19,1,19,3],[19,4,19,5],[18,1,18,3],[18,4,18,5]]}
[]
[null,"基本データシート"]
[]
[null,"施術者データ",null,null,null,null,null,null,"　白ヌキのセルは自分で入力してください"]
[null,"施術者氏名","福岡太郎"]
[null,"施術者住所","812-0011","福岡県福岡市博多駅2丁目12-3",null,null,null,"院名","福岡鍼灸院"]
[null,"施術者電話","092-123-4567"]
[null,"中央団体施術者登録番号","400010019577BU",null,null,{"$f":"LEN(C8)","v":14}]
[null,"福岡広域連合登録NO","4081600477",null,null,{"$f":"LEN(C9)","v":10}]
[null,"受領委任登録記号番号","40000141-0-0",null,null,{"$f":"LEN(C10)","v":12}]
[null,"機関コード",null,null,null,null,null,null,null,null,null,null,null,"令和6年6月1日施術分より料金改定予定　初検料1術1,950円　初検料2術2,230円  1術1,610円  2術1,770円　電療料100円　訪問施術料1①1術1回につき3,910円、②2術1回4,070円　訪問施術２、①1術2,760円、②2術1回2,920円　訪問施術３、①1術1回2,070円、②2術1回2230円、　訪問施術（10人以上の場合）①1術1回1,760円、②2術1回1,920円、　電気温灸器等1回につき100円加算。　特別地域加算1回につき250円、　往療料4km2,300円　施術報告書交付料480円　"]
[]
[null,"初検料","１術",null,1950]
[null,null,"２術",null,2230,null,"訪問施術料","①","②","③3人～9人","③10人以上"]
[null,"施術料","１術",null,1610,null,"１術",3910,2760,2070,1760]
[null,null,"２術",null,1770,null,"２術",4070,2920,2230,1920]
[null,"電療加算",null,null,100]
[null,"　　往療　４ｋｍ　まで",null,null,2300]
[null,"　　特別地域（加算）",null,null,250]
[null,"施術報告書交付料",null,null,480]
[]
[]
[null,"代理人住所","福岡市博多区神屋町2-4 フラワービル２F"]
[null,"代理人（法人）","公益社団法人福岡県鍼灸マッサージ師会"]
[null,"代理人氏名","会長　仲嶋　隆史"]
[null,"銀行名","福岡銀行"]
[null,"支店名","本店営業部"]
[null,"口座番号","6637113"]
[null,"口座名義人フリガナ","シャ）フクオカケンシンキュウマッサージシカイ"]