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[]
[null,null,null,"○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、精神障害などによる外出困難　3．その他（　　　　　　　　　　　　　　　　　））"]
[]
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[]
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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,null,null,"3．郵便局送金",null,null,null,null,null,null,null,null,null,null,"4．当 地 払",null,null,null,null,null,null,null,null,null,null,null,null,null,"2．通知",null,null,null,null,null,null,null,"4．別段"]
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[]
[null,null,null,null,null,"カタカナで記入"]
[]
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[null,null,"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。",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AH1","v":"令和"},null,null,null,{"$f":"AM1","v":7},null,null,null,"年",null,{"$f":"AR1","v":5},null,null,null,"月",null,{"$f":"X61","v":26},null,null,null,"日"]
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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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[]
[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","400010019577AV",null,null,{"$f":"LEN(C8)","v":14}]
[null,"福岡広域連合登録NO","4081600477"]
[null,"受領委任登録記号番号","40000141-0-0",null,null,{"$f":"LEN(C10)","v":12}]
[null,"機関コード",null,null,null,null,null,null,null,null,null,"1局所","2局所","3局所","4局所","5局所"]
[null,null,null,null,null,null,null,null,"通所",null,null,450,900,1350,1800,2250]
[null,"マッサージ（1局所につき）",null,null,"廃止",null,null,null,"訪問施術料　1",null,null,2750,3200,3650,4100,4550]
[null,"変型徒手矯正施術（1肢につき）",null,null,470,null,null,null,"訪問施術料　2",null,null,1600,2050,2500,2950,3400]
[null,"温罨法（1肢につき加算）",null,null,180,null,null,null,"訪問施術料　3（3人～9人）",null,null,910,1360,1810,2260,2710]
[null,"温罨法・電気光線器具",null,null,300,null,null,null,"訪問施術料　3（10人以上）",null,null,600,1050,1500,1950,2400]
[]
[null,"　　往療　４ｋｍ　まで",null,null,2300]
[null,"　　特別地域（加算）",null,null,250,null,null,null,"令和6年6月1日施術分より料金改定予定　マッサージ1局所450円、2局所900円、3局所1,350円、4局所1,800円、5局所2,250円　　訪問施術１　1局所2,750円、2局所3,200円、3局所3,650円、4局所4,100円、5局所4,550円　訪問施術2　1局所1,600円、2局所2,050円、3局所2,500円、4局所2,950円、5局所3,400円　訪問施術3　1局所910円、2局所1,360円、3局所1,810円、4局所2,260円、5局所2,710円　訪問施術3（10人以上）1局所600円、2局所1,050円、3局所1,500円、4局所1,950円、5局所2,400円　温罨法180円、電気光線器具300円、徒手矯正術470円、特別地域加算250円　往療料4km2,300円、　施術報告書交付料480円　"]
[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２階"]
[null,"代理人氏名","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"]