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["医療費助成制度該当・非該当(変更)届"]
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["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",{"$nulls":5},"被保険者\n氏名",{"$nulls":14},1,"株式会社豊田自動織機",2021,0,1]
[{"$nulls":30},3,"豊田自動織機労働組合",2022,1,2]
[null,"被保険者の\n住所\n電話番号",null,null,null,"〒",null,null,"-",{"$nulls":9},"自宅TEL（",null,null,"）",null,null,"-",{"$nulls":5},10,"株式会社サンバレー",2023,2,3]
[{"$nulls":8},"都道\n府県",{"$nulls":9},"携帯TEL（",null,null,"）",null,null,"-",{"$nulls":5},11,"医療法人豊田会 刈谷豊田総合病院",2024,3,4]
[{"$nulls":30},20,"株式会社豊田自動織機ITソリューションズ",2025,4,5]
[null,"会社名",{"$nulls":28},32,"株式会社ユニカ",2026,5,6]
[{"$nulls":30},33,"ミヅホ工業株式会社",2027,6,7]
[null,"受給対象者\nの氏名",{"$nulls":8},"受給対象者\nの生年月日",null,null,"　　昭和　　平成　　令和",{"$nulls":7},"被保険者\nとの続柄",{"$nulls":8},34,"株式会社アルテックス",2028,7,8]
[{"$nulls":16},"年",null,"月",null,"日",{"$nulls":9},35,"株式会社ハラテックス",2029,8,9]
[null,"受給対象者\nの住所",null,null,null,"〒",null,null,"-",null,null,"都道\n府県",{"$nulls":18},36,"株式会社半田キャスティング",2030,9,10]
[{"$nulls":30},37,"イヅミ工業株式会社",null,10,11]
[null,"医療助成①",null,null,null,"助成の名称",{"$nulls":20},"(下記の医療助成の一覧から選んで記入してください)",null,null,null,38,"株式会社長尾工業",null,11,12]
[{"$nulls":5},"発行機関",null,null,"国・都道府県（　　　　　　　都・道・府・県",null,null,null,"都・道・府・県",{"$nulls":4},"）・市町村（",null,null,"市・町・村",{"$nulls":5},"）",null,null,null,39,"仁科工業株式会社",null,12,13]
[{"$nulls":5},"届出理由",null,null,null,"新たに助成を受けた・変更があった",{"$nulls":9},"助成が終了した",{"$nulls":10},40,"株式会社サンスタッフ",null,null,14]
[{"$nulls":20},"助成を受けなくなった日",{"$nulls":9},50,"株式会社エスケイエム",null,null,15]
[{"$nulls":20},"令和　　　年　　　月　　　日",{"$nulls":9},51,"アドバンスト・ロジスティックス・ソリューションズ株式会社",null,null,16]
[{"$nulls":8},"区分",null,null,"窓口での支払い",{"$nulls":18},52,"大興運輸株式会社",null,null,17]
[{"$nulls":5},"助成内容",null,null,null,"入院",null,"□負担なし　　□1割負担　　□2割負担　　□定額負担　　□償還払い",{"$nulls":18},53,"トヨタL&F静岡株式会社",null,null,18]
[{"$nulls":5},"(該当する□に✓)",null,null,null,"通院",null,"□負担なし　　□1割負担　　□2割負担　　□定額負担　　□償還払い",{"$nulls":18},61,"株式会社豊田自動織機ウェルサポート",null,null,19]
[{"$nulls":9},"薬局",null,"□負担なし　　□1割負担　　□2割負担　　□定額負担　　□償還払い",{"$nulls":18},80,"株式会社シャインズ",null,null,20]
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[null,"医療助成②",null,null,null,"助成の名称",{"$nulls":20},"(下記の医療助成の一覧から選んで記入してください)",null,null,null,99,"任意継続",null,null,22]
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[{"$nulls":20},"令和　　　年　　　月　　　日",{"$nulls":13},26]
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[]
["【医療助成の一覧】"]
[null,"障害者医療",{"$nulls":4},"育成医療",{"$nulls":4},"更生医療",{"$nulls":4},"精神通院医療",{"$nulls":4},"肝炎治療の医療費助成制度",{"$nulls":8},"障害者医療"]
[null,"指定難病(小児慢性特定疾患）",{"$nulls":9},"ひとり親家庭等医療助成",{"$nulls":9},"生活保護",{"$nulls":8},"育成医療"]
[null,"その他<名称を記載してください>",{"$nulls":28},"更生医療"]
[null,"・個人情報について",{"$nulls":28},"精神通院医療"]
[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。",{"$nulls":27},"肝炎治療の医療費助成制度"]
[null,null,"詳しくは　https://www.shokki-kenpo.jp/policy　をご覧ください。",{"$nulls":27},"指定難病(小児慢性特定疾患）"]
[null,"【注意事項】",{"$nulls":28},"ひとり親家庭等医療助成"]
[null,"・データ入力またはボールペンで記入し、書き損じた場合は訂正個所に訂正印を押してください。",{"$nulls":28},"生活保護"]
[null,"・受給者証、証明書等をお持ちの方は必ず写しを裏面に貼りつけて提出してください。",{"$nulls":28},"その他<名称を記載してください>"]
[null,"・複数の医療助成を受給されている方は、全て提出してください。（3つ以上の場合は届出用紙を複数枚使用してください）"]
[null,"・上記事項に変更が生じた時（助成が終了した時を含む）は速やかに提出してください。"]
[null,"・受給認定期間が満了になり、再度継続される場合も速やかに提出してください。"]
[null,"・健保組合では、医療費の自己負担分に対して規約に基づき付加金等を支給しております。"]
[null,"　届出遅延により付加金を支給していた場合は、受給開始日に遡り返納していただきます。"]
["健保記入欄","該当届入力年月日",{"$nulls":5},"令和",null,null,"年",null,"月",null,"日"]
[null,"非該当届入力年月日",{"$nulls":5},"令和",null,null,"年",null,"月",null,"日",{"$nulls":8},"健保受付印"]
[null,"決　裁","常務理事",null,null,"事務長",null,null,"ＧＭ",null,null,"担当",{"$nulls":5},"作業完了"]
[]
[]
[]
[{"$nulls":26},"(ver.1.10　R3.8.1）"]
[]
["医療費助成制度該当・非該当(変更)届　裏面"]
[]
["※医療助成制度該当・非該当(変更)届の裏面に『医療受給者証』等の証明書の写しを貼り付けてください。"]
{"$rows_empty":14}
[null,"・健保組合では、医療費の自己負担分に対して規約に基づき付加金等を支給しております。"]
[null,"　届出遅延により付加金を支給していた場合は、受給開始日に遡り返納していただきます。"]
[null,"・届出いただいた個人情報は健保組合からの案内ならびに保険給付金等の支払いに使用する"]
[null,"　場合があります。"]
{"$rows_empty":19}
[null,"・提出ルート"]
{"$rows_empty":9}
[null,null,null,"お問い合わせ先",{"$nulls":4},"〒448-0847",null,null,null,"愛知県刈谷市宝町8丁目1番地"]
[{"$nulls":12},"豊田自動織機健康保険組合　医療保険グループ"]
[{"$nulls":13},"外線　0566-21-7784　"]
[{"$nulls":13},"内線　70-4612"]
[]
[{"$nulls":26},"(ver.1.10　R3.8.1）"]