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{"sheet":"申請書","index":0,"n_rows":39,"n_cols":29,"rows_kept":39,"cut":false,"hidden":false,"merged":[[22,10,22,18],[23,10,24,16],[25,10,25,26],[26,17,26,26],[27,17,27,26],[22,1,27,2],[9,8,9,14],[9,18,9,21],[10,4,10,14],[10,18,10,28],[14,18,14,20],[13,1,14,3],[13,15,14,17],[18,18,18,28],[16,18,16,20],[16,21,16,28],[18,9,18,11],[18,12,18,13],[14,22,14,28],[13,4,14,14],[17,4,17,6],[9,1,9,3],[9,15,9,17],[10,1,10,3],[10,15,10,17],[11,1,12,3],[11,8,12,8],[9,4,9,6],[11,11,12,11],[11,14,12,14],[11,4,11,5],[11,12,12,13],[11,9,12,10],[11,6,12,7],[9,23,9,24],[9,26,9,27],[11,28,12,28],[11,26,12,27],[11,23,12,24],[11,20,12,21],[12,4,12,5],[11,25,12,25],[11,15,12,17],[15,1,16,3],[15,4,16,14],[15,15,16,17],[15,18,15,20],[11,18,11,19],[12,18,12,19],[11,22,12,22],[20,1,21,2],[20,3,21,3],[15,21,15,22],[15,24,15,27],[17,15,17,16],[17,22,17,23],[17,1,17,3],[17,9,17,14],[18,1,18,8],[22,3,27,3],[21,9,21,25],[22,20,22,22],[22,24,22,26],[23,19,24,25],[18,15,18,16],[23,4,24,9],[26,4,27,9],[26,10,26,16],[27,10,27,16],[36,20,36,22],[36,23,36,25],[36,26,36,28],[38,5,39,8],[37,5,37,8],[37,9,37,15],[38,9,39,15],[36,5,36,15],[36,17,36,19]],"flags":["formulas_cached_only"]}
[null,"豊田自動織機健康保険組合　保健事業G　行き"]
[]
[null,"特定不妊治療費補助申請書"]
[]
[null,"下記のとおり特定不妊治療費の補助を申請します。"]
[null,"申請にあたり、自治体、指定医療機関及び調剤薬局等と健康保険組合の間において、特定不妊治療補助事業に"]
[null,"関する情報の照会及び提供を行うことについて同意します。"]
[]
[null,null,null,"太枠の中をご記入願います。"]
[null,"保険証の\n記号・番号",{"$nulls":5},"－",{"$nulls":7},"申請日",{"$nulls":6},"年",null,null,"月",null,null,"日"]
[null,"被保険者\n氏名",{"$nulls":13},"配偶者\n氏名"]
[null,"生年月日",null,null,"昭和",null,null,null,"年",null,null,"月",null,null,"日","生年月日",null,null,"昭和",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":4},"平成",{"$nulls":13},"平成"]
[null,"会社名",{"$nulls":13},"保険証の\n記号・番号",null,null," (配偶者も被保険者の場合)"]
[]
[null,"部署名",{"$nulls":13},"職場\n連絡先",null,null,"内線：",{"$nulls":4},"－"]
[{"$nulls":18},"外線："]
[null,"健保\n申請回数",{"$nulls":5},"回目",null,"今回の治療期間",{"$nulls":7},"年",null,"月",null,"日～",null,null,"年",null,"月",null,"日"]
[null,"他健保組合の補助利用",{"$nulls":7},"な し ",null,null,"☐",null,null,"あ り ",null,"☐","（この場合は織機健保の補助が利用できません）"]
[null,"自治体等からの助成について"]
[null,"なし",null,"☐",null,"１．収入制限超え　　　２．年齢制限超え　　　３．回数制限超え　　　４．海外勤務のため"]
[{"$nulls":5},"５．その他　（　",{"$nulls":20},"）"]
[null,"あり ",null,"☐","自治体等助成申請日",{"$nulls":14},"年",null,null,null,"月",null,null,null,"日"]
[{"$nulls":4},"助成を受けた\n自治体等の名称",{"$nulls":12},"都","道",{"$nulls":7},"市","町"]
[{"$nulls":17},"府","県",{"$nulls":7},"区","村"]
[{"$nulls":4},"今回の治療費",{"$nulls":22},"円"]
[{"$nulls":4},"助成を受けた額",{"$nulls":5},"特定不妊治療\n(男性不妊治療費除く)",{"$nulls":16},"円"]
[{"$nulls":10},"男性不妊治療",{"$nulls":16},"円"]
[]
[null,"【申請時にご確認ください】",{"$nulls":16},"【申請期限】"]
[null,"□","[添付]",null,"特定不妊治療受診等証明書＜健保フォーマット＞"]
[{"$nulls":4},"(自治体へ提出の証明書の写しでも可）"]
[null,"□","[添付]",null,"続柄記載の住民票 または 戸籍謄本(別居の場合)"]
[null,"□","[添付]",null,"助成額が記載された自治体発行の通知書の写し"]
[null,"□","[添付]",null,"院外処方の場合は調剤薬局発行の領収書の写し"]
[]
[null,"健保受付",null,null,null,"健保記入欄",{"$nulls":11},"常務理事",null,null,"事務長",null,null,"GM",null,null,"担当"]
[{"$nulls":5},"補助可否",null,null,null,"補助金額"]
[{"$nulls":5},"可　・　不可",null,null,null,"円"]