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["令和　　　年　　　月分",{"$nulls":16},"柔道整復施術療養費請求書"]
[]
[]
[]
["保険者",null,"市 町 村\n国保組合"]
[{"$nulls":34},"県番",null,null,"柔整",null,null,"施術機関コード番号",{"$nulls":12},"給付割"]
[]
[{"$nulls":34},41,null,null,7,{"$nulls":15},10,null,9]
[null,null,"コード",{"$nulls":28},"殿"]
[{"$nulls":53},8,null,7]
[]
[null,"下記のとおり請求する。\n令和　　年　　月　　日"]
[]
[]
[]
[]
[{"$nulls":24},"施術所の所在地\n及　び　名　称\n柔道整復師氏名"]
[]
[]
[]
[]
[]
["区　　　　　分",{"$nulls":16},"件　　数",{"$nulls":5},"日　　数",{"$nulls":5},"施術総金額（円）",{"$nulls":11},"請求金額（円）",{"$nulls":10},"備　考"]
[]
["国　民　健　康　保　険",null,25,null,"⑧",null,"70歳以上\n一般・低所得",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[null,null,"　一般被保険者",null,"⓪",null,"70歳以上\n　7 割",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[{"$nulls":4},"②",null,"　一般\n被保険者",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[{"$nulls":4},"④",null," 就学前",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[null,null,67,null,"②",null," 本人",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[null,null,"退　職　者",null,"⑧",null,"70歳以上\n一般・低所得",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[{"$nulls":4},"⓪",null,"70歳以上\n　7 割",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[{"$nulls":4},"⑥",null,"被扶養者",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[{"$nulls":4},"④",null," 就学前",{"$nulls":5},"請求"]
[]
[]
[{"$nulls":12},"※決定"]
[]
["備　考"]
{"$rows_empty":17}
[null,null,null,"1.※印の欄は、記入しないこと。\n2.国保組合分については、給付割合別に作成すること。\n3.この請求書を療養費支給申請書に添付すること。"]
["備考",{"$nulls":28},"振　込\n銀行名"]

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["令和　　　年　　　月分",{"$nulls":16},"柔道整復施術療養費請求書"]
[]
[]
[]
[]
["保険者",null,"佐賀県後期高齢者医療広域連合",{"$nulls":31},"県番",null,null,"柔整",null,null,"施術機関コード番号"]
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[{"$nulls":34},41,null,null,7]
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[null,null,"コード",{"$nulls":9},3,null,9,null,4,null,1,null,0,null,0,null,0,null,6,null,null,"殿"]
[]
[null,"下記のとおり請求する。\n令和　　年　　月　　日"]
[]
[]
[]
[]
[]
[{"$nulls":22},"施術所の所在地\n及び名称\n柔道整復師氏名"]
[]
[null,"後期高齢者医療"]
[]
[]
[]
["区　　　　　　　　　分",{"$nulls":16},"件　　数",{"$nulls":5},"日　　数",{"$nulls":5},"施術総金額（円）",{"$nulls":11},"　請求金額（円）",{"$nulls":10},"備　考"]
[]
[39,null,null,null,"⑧ ",null,"後期高齢者\n 一般・低所得",{"$nulls":6},"請求"]
[]
[]
[{"$nulls":13},"※決定"]
[]
[{"$nulls":4},"⓪",null,"後期高齢者\n　７割",{"$nulls":6},"請求"]
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[]
[{"$nulls":13},"※決定"]
[]
[]
[]
["備　考"]
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[null,null," 1.※印の欄は、記入しないこと。\n 2.この請求書を療養費支給申請書に添付すること。\n",{"$nulls":26},"振　込\n銀行名"]
["備考"]