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["別紙第23"]
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[{"$nulls":12},"外科後処置費用支給申請書"]
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["　　　　　　　　　　　　　　　　　　　　　",{"$nulls":16},"殿","（申請者の住所）　　　　　　　　　　　　　　　　"]
["　 下記の外科後処置費用の支給を受けたいので申請します。",{"$nulls":17},"（氏        名）"]
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["１（所属部局）",{"$nulls":17},"２（生年月日）"]
[{"$nulls":29},"年",null,"月",null,"日生"]
["３（官職）　",null,null,null,"□","常　勤",{"$nulls":12},"４　福祉事業の実施\n　　の承認年月日"]
[{"$nulls":4},"□","非常勤",{"$nulls":20},"令和",null,null,"年",null,"月",null,"日"]
[null,null,"薬剤",null,null,null,"（薬名及び使用量）"]
["※５",{"$nulls":32},"円"]
["医　師　等　の　証　明",null,"治療材料",null,null,null,"（材料及び数量）"]
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[null,null,"温泉療法",null,null,null,"（期間）"]
[{"$nulls":33},"円"]
[null,null,"□","マッサージ",null,null,"（期間及び回数）"]
[null,null,"□","はり"]
[null,null,"□","きゅう",{"$nulls":29},"円"]
[null,null,"その他"]
[{"$nulls":33},"円"]
[null,null,"　上記の事項は事実と相違ないことを証明します。"]
[{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":15},"所在地"]
[{"$nulls":8},"病院又は診療所等の",{"$nulls":6},"名称"]
[{"$nulls":15},"医師等の氏名"]
["６ 看　　護　　料",{"$nulls":5},"□","訪問看護　内訳は「10訪問看護事業者の証明」欄記載のとおり",{"$nulls":21},{"$f":"'（別紙第２３）２号紙'!E29","v":0},null,null,null,"円"]
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[{"$nulls":20},"日間"]
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["７ 移　　送　　費",{"$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"]
["８日　　　　　　当",{"$nulls":8},"令和",null,null,null,"年",null,null,"月",null,null,"日から"]
[{"$nulls":23},"日間"]
[{"$nulls":9},"令和",null,null,null,"年",null,null,"月",null,null,"日まで",{"$nulls":13},"円"]
["９ 外科後処置費用支給申請額",{"$nulls":28},{"$f":"AD14+AD16+AD18+AD21+AD23+AD29+AD32+AD36+AD37+AD40","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　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　「６　看護料」及び「７　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及び\n　　　　　　明細書を添付すること。"]
["　　　　　３　「５　医師の証明」欄の記入又は２号紙の記入に代えて同様事項を記載した医師等又は訪問看護事業者の証明書を添付\n　　　　　　してもよい。"]

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["※10　訪問看護事業者の証明",{"$nulls":9},"(患者氏名)"]
["傷　病　名",{"$nulls":9},"(訪問看護期間)"]
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["傷病の経過",{"$nulls":10},"令和",null,null,"年",null,"月",null,"日まで"]
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[null,"保健師、看護師、理学療法士、作業療法士",{"$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。"]
[null,null,null,"令和",null,"年",null,"月",null,"日"]
[{"$nulls":7},"所在地"]
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[{"$nulls":7},"代表者氏名"]
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["　　　　　３　「５　医師の照明」欄の記入又は２号紙の記入に代えて同様事項を記載した医師等又は訪問看護事業者の証明書を添付\n　　　　　　してもよい。"]