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["健康保険限度額適用認定申請書"]
[]
["豊田自動織機健康保険組合　御中",{"$nulls":18},"提出日",null,null,null,"年",null,null,"月",null,null,"日",null,null,null,1,"株式会社豊田自動織機","2021","1","1"]
["被保険者記入欄","保険証の\n記号番号",null,null,null,"記号",null,null,null,"番号",{"$nulls":6},"被保険者\n氏名",{"$nulls":16},3,"豊田自動織機労働組合","2022","2","2"]
[{"$nulls":33},10,"株式会社サンバレー","2023","3","3"]
[null,"被保険者の\n住所\n電話番号",null,null,null,"〒",null,null,"－",{"$nulls":10},"自宅TEL（　　　　",{"$nulls":4},")",null,null,"-",{"$nulls":5},11,"医療法人豊田会 刈谷豊田総合病院","2024","4","4"]
[{"$nulls":8},"都道\n府県",{"$nulls":10},"携帯TEL（",{"$nulls":4},")",null,null,"-",{"$nulls":5},20,"株式会社豊田自動織機ITソリューションズ","2025","5","5"]
[{"$nulls":33},32,"株式会社ユニカ","2026","6","6"]
[null,"会社名",{"$nulls":31},33,"ミヅホ工業株式会社","2027","7","7"]
[{"$nulls":33},34,"株式会社アルテックス","2028","8","8"]
[null,"認定対象者の\n氏名",{"$nulls":16},"認定対象者\nの生年月日",null,null,null,"昭和",null,null,"平成",{"$nulls":7},35,"株式会社ハラテックス","2029","9","9"]
[{"$nulls":22},"令和",null,null,"年",null,"月",null,"日",null,null,null,36,"株式会社半田キャスティング","2030","10","10"]
[null,"入院(通院)の\n医療機関名称",{"$nulls":31},37,"イヅミ工業株式会社",null,"11","11"]
[{"$nulls":33},38,"株式会社長尾工業",null,"12","12"]
[null,"入院(通院)の\n期間",{"$nulls":31},39,"仁科工業株式会社",null,null,"13"]
[{"$nulls":12},"年",null,null,"月",null,null,"日",null,null,"から翌々月末まで",{"$nulls":11},40,"株式会社サンスタッフ",null,null,"14"]
[null,"傷病名",{"$nulls":31},50,"株式会社エスケイエム",null,null,"15"]
[{"$nulls":33},51,"アドバンスト・ロジスティックス・ソリューションズ株式会社",null,null,"16"]
[null,"今回の入院理由は、第三者の行為(交通事故・喧嘩等）で受傷したものですか？",{"$nulls":22},"はい",null,null,"いいえ",{"$nulls":5},52,"大興運輸株式会社",null,null,"17"]
[null,"今回の入院理由は、通勤途中、業務中の傷病によるものですか？",{"$nulls":22},"はい",null,null,"いいえ",{"$nulls":5},53,"トヨタL&F静岡株式会社",null,null,"18"]
[null,"今回の入院で、医療費の窓口負担はありますか？",{"$nulls":22},"はい",null,null,"いいえ",{"$nulls":5},61,"株式会社豊田自動織機ウェルサポート",null,null,"19"]
[{"$nulls":33},80,"株式会社シャインズ",null,null,"20"]
[{"$nulls":33},81,"株式会社サンリバ－",null,null,"21"]
[null,null,"マイナ保険証で受診すると、限度額認定証がなくても、本人が同意すれば高額医療費制度に基づき",{"$nulls":30},99,"任意継続",null,null,"22"]
[{"$nulls":37},"23"]
[null,null,"限度額を超える医療費の立替払いが不要となります。健保組合への手続きは必要ありません。",{"$nulls":34},"24"]
[{"$nulls":37},"25"]
[null,null,"マイナ保険証をぜひご利用ください。",{"$nulls":34},"26"]
[{"$nulls":37},"27"]
[{"$nulls":33},81,"株式会社サンリバ－",null,null,"28"]
[null,"・データ入力またはボールペンで記入し、書き損じた場合は訂正個所に訂正印を押してください。",{"$nulls":35},"29"]
[{"$nulls":37},"30"]
[null,"・提出ルート",{"$nulls":35},"31"]
[]
[]
[]
[]
[]
[null,"・個人情報について"]
[null,null,"ご記入いただいた個人情報は、健保組合からのご案内や保険給付金等の支払いに使用する場合があります。"]
[null,null,"詳しくは　https://www.shokki-kenpo.jp/contents/privacy/index.html　をご覧ください。"]
[null,"　　","マイナンバーで申請したい方は健康保険組合までご連絡ください。"]
[]
[]
[null,null,null,"お問い合わせ先",{"$nulls":4},"〒448-0847",{"$nulls":4},"愛知県刈谷市宝町8丁目1番地"]
[{"$nulls":13},"豊田自動織機健康保険組合　医療保険グループ"]
[{"$nulls":14},"外線　0566-21-7784　"]
[{"$nulls":14},"内線　70-4612"]
[]
[]
[]
[]
["健保記入欄","決定事項",{"$nulls":4},"交付・却下",null,null,null,"(理由　",{"$nulls":6},"）"]
[null,"発効年月日",{"$nulls":4},"令和",null,null,"年",null,null,"月",null,null,"日"]
[null,"有効期限",{"$nulls":4},"令和",null,null,"年",null,null,"月",null,null,"日",{"$nulls":10},"健保受付印"]
[null,"適用区分"]
[null,"決　裁","常務理事",null,null,"事務長",null,null,"ＧＭ",null,null,"担当"]
[]
[]
[]
[{"$nulls":29},"2024.4.1改訂(xls版）"]
[]
[]
[]
[]
[null,"念　　　書"]
[]
["■健康保険限度額適用認定証の取扱いについて"]
[]
[]
["１．限度額適用認定証の有効期限は、申請を受け付けた月の１日から３ヶ月間です。"]
[]
["　　有効期限に達した時は速やかに返却してください。"]
[]
["　　また有効期限を越えて使用する場合は再度申請が必要です。"]
[]
["２．保険医療機関等から入院療養等を受ける際には、窓口に被保険者証と認定証を提出してください。"]
[]
["３．事前申請のため退院後の申請は、認められません。"]
[]
["　　また前月に遡っての発行はできません。"]
[]
["４．公費該当者で、市区町村などから医療助成を受けている方は申請できません。"]
[]
["5．被保険者が以下に該当したときは証を返納する。"]
[]
["　　・被保険者が資格を喪失したとき"]
[]
["　　・加入している保険者に変更があったとき"]
[]
["　　・適用対象者の被扶養者が被扶養者でなくなったとき"]
[]
["　　・認定証の有効期限に達したとき"]
[]
["　　・適用対象者が老人医療受給対象者となったとき"]
[]
["６．上記理由の他に健康保険組合から認定証の返納を求められた場合、即時返納する。"]
[]
["７. 住民税非課税世帯の方は、ご連絡ください。"]
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[null,"上記事項に同意して、健康保険限度額適用認定証を使用します。"]
[]
[null,"    年",null,"       月  ",null,"       日"]
[]
[null,null,null,"氏名（自筆）"]