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{"sheet":"限度額申請書","index":0,"n_rows":53,"n_cols":32,"rows_kept":53,"cut":false,"hidden":false,"merged":[[9,31,11,31],[8,15,8,17],[5,0,5,25],[8,23,8,25],[8,19,8,21],[7,12,8,13],[10,10,11,13],[10,6,11,9],[9,4,11,5],[9,16,11,17],[9,18,11,25],[0,17,0,19],[1,17,3,19],[1,23,3,25],[1,20,3,22],[0,23,0,25],[0,20,0,22],[47,20,47,24],[49,3,49,5],[49,6,49,10],[49,11,49,12],[7,4,7,7],[7,8,7,11],[8,4,8,7],[8,8,8,11],[7,0,8,3],[7,14,7,25],[21,5,21,7],[15,14,17,17],[15,18,17,25],[12,18,14,25],[31,0,31,24],[46,3,46,7],[37,24,37,25],[27,7,27,9],[34,0,34,24],[33,0,33,24],[32,0,32,24],[30,0,30,24],[27,0,28,5],[52,0,52,1],[9,0,14,3],[15,0,20,3],[18,4,20,5],[22,5,24,24],[21,9,21,12],[9,14,14,15],[46,19,46,25],[28,7,28,24],[29,7,29,24],[40,3,42,22],[39,3,39,22],[21,0,24,3],[25,0,25,25],[26,0,26,12],[29,0,29,5],[18,18,20,25],[15,4,17,5],[12,4,14,5],[16,6,17,9],[16,10,17,13],[18,14,20,17],[12,16,14,17],[12,6,14,13],[18,6,20,13]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"課長",null,null,"課長補佐",null,null,"担当者"]
[]
[]
[]
[]
["健康保険限度額適用認定申請書"]
[]
["被保険者等\n記号・番号",null,null,null,"記号",null,null,null,"番号",null,null,null,"認定証\n送付先",null,"いずれかにチェックを入れてください",null,null,null,null,null,null,null,null,null,null,null,null,null,"前回入力した情報を保存している場合は、別人の情報が残るのを避けるため"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自宅",null,null,false,"事業所",null,null,null,"その他",null,null,null,null,"下のリセットボタンを押して、全て消去してから入力してください。"]
["被保険者",null,null,null,"氏名",null,"(氏)",null,null,null,"(名)",null,null,null,"お勤め先の",null,"事業所\n名　称",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"↓"]
[]
[]
[null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,null,"所在地"]
[]
[]
["認定証交付\n対象者\n被保険者の場合\nは記入不要",null,null,null,"氏名",null,"(氏)",null,null,null,"(名)",null,null,null,"被保険者\nとの続柄"]
[]
[]
[null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,"療養開始日\n（使用開始予定日）"]
[]
[]
["被保険者の住所\n\n電話番号\n（日中の連絡先）",null,null,null,"〒",null,null,null,"TEL"]
[]
[]
[]
["※　申請内容について確認させていただく場合があります。必ず、日中連絡のつく連絡先をご記入ください。"]
["被保険者の住所（自宅）以外に送付を希望する場合"]
["送付先住所",null,null,null,null,null,"〒"]
[]
["宛　　　名"]
["※マイナ保険証を利用されている方には、認定証は発行されません。"]
["※資格確認書をお持ちの方には認定証を発行します。"]
["※認定証の有効期限は、原則、申請月（当組合の受付月）の初日から１年間となります。"]
["※前月分医療費の支払いが未済等により、前月分からの発効を希望する場合は、医療機関に確認のうえ申請いただく"]
["　際に管轄の本・支部（本部業務部：℡03-3866-2865、多摩支部業務課：03-5839-2441）にご連絡ください。"]
[]
[null,null,null,"うえのとおり健康保険限度額適用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,"令和",null,"年",null,"月",null,"日提出"]
[]
[null,null,null,"●マイナ保険証の利用で限度額適用認定申請が不要になります●"]
[null,null,null,"マイナ保険証(マイナンバーカードに保険証利用の登録をしたもの)を利用すれば、限度額適用認定証を提示しなくても高額療養費制度における限度額を超える支払いが免除されます。\nこの限度額適用認定申請書の提出は不要となりますので、マイナ保険証をぜひご利用ください。"]
[]
[]
[]
[]
[]
[null,null,null,"【健康保険組合処理欄】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"東京金属事業健康保険組合"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付日付印"]
[]
[null,null,null,"標準報酬月額",null,null,null,null,null,null,null,"千円"]
[]
[]
["2025-04-01"]