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["健康保険特定疾病療養受療証交付申請書"]
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["豊田自動織機健康保険組合　御中",{"$nulls":17},"提出日",null,null,null,"年",null,null,"月",null,null,"日",null,1,"株式会社豊田自動織機","2021","1","1"]
["被保険者記入欄","保険証の\n記号番号",null,null,null,"記号",null,null,null,"番号",{"$nulls":5},"被保険者\n氏名",{"$nulls":14},3,"豊田自動織機労働組合","2022","2","2"]
[{"$nulls":30},10,"株式会社サンバレー","2023","3","3"]
[null,"被保険者の\n住所・電話番号",null,null,null,"〒",null,"－",{"$nulls":10},"自宅TEL　（　　　　　　）　　　　　－",{"$nulls":4},"）",null,null,"-",null,null,null,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":9},"携帯TEL　（",{"$nulls":4},"）",null,null,"-",null,null,null,20,"株式会社豊田自動織機ITソリューションズ","2025","5","5"]
[{"$nulls":30},32,"株式会社ユニカ","2026","6","6"]
[null,"会社名",{"$nulls":28},33,"ミヅホ工業株式会社","2027","7","7"]
[{"$nulls":30},34,"株式会社アルテックス","2028","8","8"]
[null,"認定対象者の\n氏名",{"$nulls":8},"認定対象者の\n生年月日",{"$nulls":4},"昭和",{"$nulls":7},"被保険者\nとの続柄",{"$nulls":6},35,"株式会社ハラテックス","2029","9","9"]
[{"$nulls":15},"平成",null,null,"年",null,"月",null,"日",{"$nulls":7},36,"株式会社半田キャスティング","2030","10","10"]
[null,"認定対象者の\n住所",null,null,null,"〒",null,"－",null,null,null,"都道\n府県",{"$nulls":18},37,"イヅミ工業株式会社",null,"11","11"]
[{"$nulls":30},38,"株式会社長尾工業",null,"12","12"]
[null,"疾病名",{"$nulls":4},"人工腎臓を実施している慢性腎不全",{"$nulls":23},39,"仁科工業株式会社",null,null,"13"]
[{"$nulls":6},"血友病",{"$nulls":23},40,"株式会社サンスタッフ",null,null,"14"]
[{"$nulls":6},"抗ウィルス剤を投与している後天的免疫不全症候群(HIVを含み、厚生労働大臣の定める",{"$nulls":23},50,"株式会社エスケイエム",null,null,"15"]
[{"$nulls":6},"ものに限る)",{"$nulls":23},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"]
[{"$nulls":30},52,"大興運輸株式会社",null,null,"17"]
["医師の意見欄",{"$nulls":29},53,"トヨタL&F静岡株式会社",null,null,"18"]
[null,null,"上記のとおり診療を受けていることに相違ありません。",{"$nulls":27},61,"株式会社豊田自動織機ウェルサポート",null,null,"19"]
[{"$nulls":30},80,"株式会社シャインズ",null,null,"20"]
[{"$nulls":6},"年",null,null,"月",null,null,"日",{"$nulls":17},81,"株式会社サンリバ－",null,null,"21"]
[{"$nulls":30},99,"任意継続",null,null,"22"]
[null,null,null,"医療機関の名称・所在地",{"$nulls":30},"23"]
[{"$nulls":34},"24"]
[null,null,null,"医師名",{"$nulls":30},"25"]
[null,null,null,"(自筆）",{"$nulls":30},"26"]
[{"$nulls":34},"27"]
[null,"・記入はデータ入力またはボールペンで、書き損じた場合は訂正個所に訂正印を押してください。",{"$nulls":32},"28"]
[{"$nulls":34},"29"]
[null,"・提出ルート",{"$nulls":32},"30"]
[{"$nulls":34},"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,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"]
[]
[]
[]
["健保記入欄","決定事項",{"$nulls":4},"交付　・　却下",null,null,null,"（理由",{"$nulls":5},"）"]
[null,"発効年月日"]
[null,"交付年月日"]
[null,"自己負担限度額",{"$nulls":17},"作業完了",{"$nulls":5},"健保受付印"]
[null,"決　裁","常務理事",null,null,"事務長",null,null,"ＧＭ",null,null,"担当"]
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