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[]
[null,"当月請求分　訪問看護療養費明細書　返戻依頼書"]
[]
[null,"【留意事項】"]
[null,"　この返戻依頼書は、当月請求された訪問看護療養費明細書の返戻依頼にのみ使用してください。"]
[null,"　必要事項を記入の上、請求された月の２０日（必着）までに、持参、または郵送により提出してください。"]
[null,"　　≪提出先≫　佐賀県国民健康保険団体連合会　審査第2課　調剤・療養費係　TEL ： 0952-26-4301"]
[]
[null,"　依頼日　　令和 　　　　年　　　　月　　　　日"]
[]
[null,"　訪問看護ステーションコード"]
[null,"　訪問看護ステーション名"]
[null,"　電話番号　　　　　　　　　　　　　　－　　　　　　　－"]
[null,"　担当者名"]
[]
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[null,null,"　保険者番号","４１○○○○／３９４１○○○○"]
[null,null,"　保険者名","佐賀県○○市（町）／佐賀県後期広域連合"]
[null,null,"　法制（該当するものを○で囲んでください。）","国保 （ 一般 ・ 退職 ） ／　後期高齢　 "]
[null,null,"　被保険者名","国保　　　太郎"]
[null,null,"　記号番号・被保険者番号",12345678]
[null,null,"　公費負担者番号",21410000]
[null,null,"　請求金額","○○○○円"]
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[null,null,"　法制（該当するものを○で囲んでください。）","国保 （ 一般 ・ 退職 ） 　後期高齢　 "]
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[null,null,"　記号番号・被保険者番号"]
[null,null,"　公費負担者番号"]
[null,null,"　請求金額"]

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