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["別紙第１"]
[]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":12},"療養補償請求書"]
[{"$nulls":33},"１号紙"]
[{"$nulls":27},"請求\n回数",null,null,"第",null,null,"回"]
[]
[]
["(実施機関の長の官職氏名)",{"$nulls":17},"請求年月日",{"$nulls":7},"令和",null,null,"年",null,"月",null,"日"]
["　　　　　　　　　　　　　　　　　　　　　",{"$nulls":16},"殿","請求者の住所　　　　　　　　　　　　　　　　"]
["　 下記の療養補償を請求します。",{"$nulls":17},"氏        名"]
[]
["(補償費用の受領委任)"]
["　 この請求書による療養補償の費用の受領を",{"$nulls":21},"に委任します。"]
[{"$nulls":18},"氏名"]
[]
["(委任に基づく支払請求)"]
["　上記委任に基づき、この請求書による療養補償の費用の支払を請求します。"]
[{"$nulls":12},"請求者の住所"]
[{"$nulls":12},"氏　　　　名"]
[]
["１（所属部局）",{"$nulls":17},"２（氏　名）"]
[{"$nulls":27},"年",null,null,"月",null,null,"日生"]
["３（官　職）　",null,null,null,"□","常　勤",{"$nulls":12},"４（負傷又は発病年月日）"]
[{"$nulls":4},"□","非常勤",{"$nulls":21},"年",null,null,"月",null,null,"日"]
["５ 診　　療　　費",{"$nulls":5},"内訳は「11医師の証明」欄記載のとおり",{"$nulls":22},{"$f":"'（別紙第１）２号紙'!V55","v":0},null,null,null,"円"]
["６ 調　　剤　　費",{"$nulls":5},"内訳は「12薬剤師の証明」欄記載のとおり",{"$nulls":22},{"$f":"'（別紙第１）３号紙'!X29","v":0},null,null,null,"円"]
["７ 看　　護　　料",{"$nulls":5},"□","訪問看護　内訳は「13訪問看護事業者の証明」欄記載のとおり",{"$nulls":21},{"$f":"'（別紙第１）４号紙'!E29","v":0},null,null,null,"円"]
[{"$nulls":6},"令和",null,null,null,"年",null,null,"月",null,null,"日から",{"$nulls":6},"看護師の資格"]
[{"$nulls":20},"日間"]
[{"$nulls":6},"令和",null,null,null,"年",null,null,"月",null,null,"日まで",{"$nulls":6},"□","有",null,"□","無",{"$nulls":5},"円"]
["８ 移　　送　　費",{"$nulls":5},"(交通費)"]
[{"$nulls":24},"□","片道"]
[{"$nulls":10},"から",{"$nulls":5},"まで",null,null,null,"キロメートル",{"$nulls":7},"回"]
[{"$nulls":24},"□","往復",{"$nulls":7},"円"]
[{"$nulls":6},"(その他の移送費)",{"$nulls":26},"円"]
["９ 上記以外の療養費",{"$nulls":32},"円"]
["10 療養補償請求金額",{"$nulls":28},{"$f":"AD26+AD27+AD28+AD31+AD35","v":0},null,null,null,"円"]
["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定金額"]
["令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日",{"$nulls":9},"円"]
[{"$nulls":24},"添付書類",{"$nulls":8},"枚"]
[]
["　　　注　１　請求者は、※印の欄には記入しないこと。該当する□にレ印を記入すること。"]
["　　　　　２　「(補償費用の受領委任)」の欄には、診療に当たった医師若しくは医療機関等、調剤に当たった\n　　　　　　薬剤師若しくは薬局又は訪問看護を行った訪問看護事業者に補償費用の受領を委任しようとする場\n　　　　　　合にのみ記載し、その他の場合には記入しないこと。"]
["　　　　　３　「７　看護料」及び「８　移送費」については、訪問看護の場合を除き、費用の領収書又はこれ\n　　　　　　に代わる証明書及び明細書を添付すること。"]
["　　　　　４　「９　上記以外の療養費」の欄には、入院料に食事料を含まない場合の食事料及び療養に必要な\n　　　　　　治療材料等の名称、数量及び費用を記入し、その領収書及び明細書を添付すること。"]
["　　　　　５　２号紙、３号紙又は４号紙の記入に代えて同様事項を記載した医師、薬剤師、柔道整復師又は訪\n　　　　　　問看護事業者の証明書を添付してもよい。"]

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["傷病名",{"$nulls":20},"(診療期間)"]
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["　 (現在の状態)",{"$nulls":11},"□","中　止",null,"□","継続中",{"$nulls":10},"日間"]
[{"$nulls":21},"診療実日数",{"$nulls":5},"日"]
["診療費の内訳",{"$nulls":20},"金　　額(円)"]
[null,"初診"]
["診　察","再診"]
[null,"在宅"]
[null,"内服"]
[null,"屯服"]
["投　薬","外用"]
[null,"調剤"]
[null,"調基"]
[null,"皮下筋肉内"]
["注　射","静脈内"]
[null,"その他"]
[null,"(処置名・回数等)"]
["処　置"]
[]
["手術・\n麻　酔","(手術名・回数等)"]
[]
[null,"(検査名・回数等)"]
["検　査"]
[]
["画　像\n診　断","(画像診断名・回数等)"]
[]
[null,"　　"]
["その他"]
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["入　院","期　間",null,null,"令和",null,"年",null,"月",null,"日","から","令和",null,"年",null,"月",null,"日まで",null,"日間"]
[null,null,"特","基","入院時基本診療料(入院料)"]
[null,"基","３","１","(室料・看護料・給食料)"]
[]
[null,"食","特","基"]
[null,null,"２","２"]
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[null,null,"特","基"]
[null,"普","１"]
[null,null,"Ⅰ"]
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[null,"食","特","本"]
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[null,null,"Ⅱ","１"]
[]
[null,null,"基","他"]
[null,"基","Ⅰ","２"]
[null,"寝"]
[null,"・","基","他"]
[null,"衣","Ⅱ","３"]
[]
[null,"その他"]
["診　療　費　の　合　計",{"$nulls":20},{"$f":"SUM(V9:AA54)","v":0},{"$nulls":5},"円"]
["　上記の事項は事実と相違ないことを証明します。"]
[{"$nulls":4},"令和",null,"年",null,"月",null,"日"]
[{"$nulls":12},"所在地"]
[{"$nulls":7},"病院又は診療所の",{"$nulls":4},"名称"]
[{"$nulls":12},"医師氏名"]

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["調 剤 費 の 内 訳",{"$nulls":22},"金　額(円)"]
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[null,"月",null,"日",null,"月",null,"日"]
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[null,"月",null,"日",null,"月",null,"日"]
["調　剤　費　の　合　計",{"$nulls":22},{"$f":"SUM(X9:Y28)","v":0},null,"円"]
["処　方　箋　の　枚　数",{"$nulls":7},"枚"]
["　上記の事項は事実と相違ないことを証明します。"]
[null,null,null,"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":12},"所在地"]
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["※13　訪問看護事業者の証明",{"$nulls":9},"(患者氏名)",null,null,{"$f":"'（別紙第１）１号紙'!W11","v":0}]
["傷　病　名",{"$nulls":9},"(訪問看護期間)"]
[{"$nulls":11},"令和",null,null,"年",null,"月",null,"日から"]
["傷病の経過",{"$nulls":10},"令和",null,null,"年",null,"月",null,"日まで"]
[{"$nulls":11},"訪問看護の回数",{"$nulls":6},"回"]
[]
[null,"保健師、看護師、理学療法士、作業療法士",{"$nulls":8},"指示年月日",{"$nulls":6},"年",null,"月",null,"日"]
["基",{"$nulls":9},"主治医への直近報告年月日",{"$nulls":6},"年",null,"月",null,"日"]
[]
["本",null,null,"円×",null,null,"回",{"$f":"B11*F11","v":0},null,"円","訪　問　日"]
[]
["療",{"$nulls":10},"１　２　３　４　５　６　７"]
[null,"准看護師",{"$nulls":9},"８　９　10　11　12　13　14"]
["養",{"$nulls":10},"15　16　17　18　19　20　21"]
[null,null,null,"円×",null,null,"回",{"$f":"B16*F16","v":0},null,"円",null,"22　23　24　25　26　27　28"]
["費",{"$nulls":10},"29　30　31"]
["管　　理\n療 養 費",null,"初日",{"$nulls":6},"円"]
[null,null,"２回目以降",null,null,"回",null,null,null,"円"]
["情報提供\n\n療 養 費",{"$nulls":9},"提供した情報の概要"]
[]
[]
[{"$nulls":9},"円","情報提供先の市(区)町村の名称"]
[]
[]
["ﾀｰﾐﾅﾙｹｱ\n療 養 費",{"$nulls":8},"円","(備　考)"]
[null,null,"死亡年月日",null,null,"年",null,"月",null,"日"]
["合　　計"]
[{"$nulls":4},{"$f":"H11+H16+G18+G19+G23+G26","v":0},{"$nulls":4},"円"]
[]
["　訪問看護を指示した医療機関の名称及び主治医の氏名"]
[null,"医療機関の名称"]
[null,"主治医氏名"]
["　上記の事項は事実と相違ないことを証明します。"]
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