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["別紙第26"]
[]
["アフターケア費用支給申請書"]
[{"$nulls":30},"１号紙"]
[{"$nulls":24},"申請",null,null,"第",null,null,"回"]
[{"$nulls":24},"回数"]
["（実施機関の長の官職氏名）",{"$nulls":15},"申請年月日",{"$nulls":6},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":15},"殿","申請者の住所"]
[]
["下記のアフターケア費用の支給を受けたいので申請します。",{"$nulls":15},"氏名"]
[]
["（アフターケア費用の受領委任）"]
["　この申請書によるアフターケア費用の受領を",{"$nulls":18},"に委任します。"]
[{"$nulls":16},"氏　　名"]
[]
["（委任に基づく支払請求）"]
["　上記委任に基づき、この申請書によるアフターケア費用の支払を請求します。"]
[{"$nulls":12},"請求者の住所"]
[]
[{"$nulls":12},"氏　　　　名"]
[]
["１ （所属部局）",{"$nulls":15},"２（官　職）",null,null,null,"□","常　勤"]
[{"$nulls":20},"□","非常勤"]
["３ （後遺症等の症状）",{"$nulls":15},"４","（治癒年月日）",{"$nulls":8},"年",null,"月",null,"日"]
["　　　　",{"$nulls":16},"（障害等級）",{"$nulls":5},"第",null,null,"級","第",null,null,"号"]
["５　診　 療　 費",{"$nulls":4},"内訳は「11医師の証明」欄記載のとおり",{"$nulls":21},{"$f":"'（別紙第２６）２号紙'!U53","v":0},null,null,"円"]
["６　調　 剤　 費",{"$nulls":4},"内訳は「12薬剤師の証明」欄記載のとおり",{"$nulls":21},{"$f":"'（別紙第２６）３号紙'!X29","v":0},null,null,"円"]
["７　看　 護　 料",{"$nulls":4},"□","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",{"$nulls":20},{"$f":"'（別紙第２６）４号紙'!G29","v":0},null,null,"円"]
[{"$nulls":5},"令和",null,null,"年",null,null,"月",null,null,"日から",null,null,null,"日間",null,null,null,"看護師の資格"]
[{"$nulls":5},"令和",null,null,"年",null,null,"月",null,null,"日まで",{"$nulls":7},"□","有","□","無",{"$nulls":4},"円"]
["８　移　 送　 費",{"$nulls":4},"（交通費）",{"$nulls":24},"円"]
[{"$nulls":8},"から",{"$nulls":4},"まで",null,null,null,"キロメートル",null,null,null,"□","片道",null,null,null,"回"]
[{"$nulls":21},"□","往復"]
[{"$nulls":5},"（その他の移送費）",{"$nulls":24},"円"]
["９　証明料その他",{"$nulls":29},"円"]
["10　アフターケア費用支給申請額",{"$nulls":25},{"$f":"SUM(AB26:AD35)","v":0},null,null,null,"円"]
["※受理",{"$nulls":6},"※決定",{"$nulls":6},"※支払",{"$nulls":6},"※決定金額"]
["令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",{"$nulls":9},"円"]
[{"$nulls":21},"添付書類",{"$nulls":8},"枚"]
[]
["　　注　１　申請者は、※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　「（アフターケア費用の受領委任）」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アフターケア費用の受領を委任しようとする場合\n　　　　　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に代わる証明書\n　　　　　及び明細書を添付すること。"]
["　　　　４　「９　証明料その他」の欄には、この申請書の証明等に要した費用等の名称、数量及び費用を記入し、その領\n　　　　　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、訪問看護事業者等の証明書を\n　　　　　添付してもよい。"]

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["診療時の症状"]
[]
[]
[]
["診療期間",null,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,"診療実日数",{"$nulls":4},"日"]
["診療費の内訳",{"$nulls":19},"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"]
[]
[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"]
[]
["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"]
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[null,null,"Ⅰ"]
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[null,"食","特","本"]
[null,null,"１","他","入院時医学管理料"]
[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",{"$nulls":19},{"$f":"SUM(U9:Z52)","v":0},{"$nulls":5},"円"]
["　上記の事項は事実と相違ないことを証明します。"]
[null,"令和",null,"年",null,"月",null,"日"]
[{"$nulls":8},"所在地"]
[null,null,null,"病院又は診療所の",{"$nulls":4},"名称"]
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[{"$nulls":10},"所在地"]
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[null,"月",null,"日",null,"月",null,"日"]
[null,"月",null,"日",null,"月",null,"日"]
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["処方箋の枚数",{"$nulls":10},"枚"]
["　上記の事項は事実と相違ないことを証明します。"]
[null,"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":12},"所在地"]
[{"$nulls":9},"薬局の",null,null,"名称"]
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["　　　　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に代わる証明書\n　　　　　及び明細書を添付すること。"]
["　　　　４　「９　証明料その他」の欄には、この申請書の証明等に要した費用等の名称、数量及び費用を記入し、その領\n　　　　　収書及び明細書を添付すること。"]

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["傷　病　名",{"$nulls":11},"(訪問看護期間)"]
[{"$nulls":13},"令和",null,null,"年",null,"月",null,"日から"]
["傷病の経過",{"$nulls":12},"令和",null,null,"年",null,"月",null,"日まで"]
[{"$nulls":13},"訪問看護の回数",{"$nulls":7},"回"]
[]
[{"$nulls":12},"指示年月日",{"$nulls":7},"年",null,"月",null,"日"]
["基",{"$nulls":11},"主治医への直近報告年月日",{"$nulls":7},"年",null,"月",null,"日"]
[]
["本","　保健師、看護師、理学療法士、作業療法士",{"$nulls":10},"訪　問　日"]
[{"$nulls":5},"円×",null,null,"回",{"$f":"B12*H12","v":0},null,"円"]
["療",{"$nulls":12},"１　２　３　４　５　６　７"]
[null,"　准看護師",{"$nulls":11},"８　９　10　11　12　13　14"]
["養",{"$nulls":4},"円×",null,null,"回",{"$f":"B15*H15","v":0},null,"円",null,"15　16　17　18　19　20　21"]
[{"$nulls":13},"22　23　24　25　26　27　28"]
["費",{"$nulls":12},"29　30　31"]
["管　　理\n療 養 費",null,"初日",{"$nulls":8},"円"]
[null,null,"２回目以降",{"$nulls":4},"回",null,null,null,"円"]
["情報提供\n\n療 養 費",{"$nulls":11},"提供した情報の概要"]
[]
[]
[{"$nulls":11},"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",{"$nulls":10},"円","(備　考)"]
[null,null,"死亡年月日",{"$nulls":4},"年",null,"月",null,"日"]
["合　　計"]
[{"$nulls":6},{"$f":"J9+J12+I18+I19+I23+I26","v":0},{"$nulls":4},"円"]
[]
["　訪問看護を指示した医療機関の名称及び主治医の氏名"]
[null,"医療機関の名称"]
[null,"主治医氏名"]
["　上記の事項は事実と相違ないことを証明します。"]
[null,"令和",null,"年",null,"月",null,"日"]
[{"$nulls":9},"所在地"]
[null,null,null,"訪問看護事業者の",{"$nulls":5},"名称"]
[{"$nulls":9},"代表者氏名"]
[]
[]
[]
[]
["　　　　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に代わる証明書\n　　　　　及び明細書を添付すること。"]
["　　　　４　「９　証明料その他」の欄には、この申請書の証明等に要した費用等の名称、数量及び費用を記入し、その領\n　　　　　収書及び明細書を添付すること。"]