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["健康保険 限度額適用認定申請書"]
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[null,"マイナンバーカード（マイナ保険証）を利用すると窓口での自己負担限度額を超えるお支払いが免除され、当申請は不要となります。限度額認定証はお手元に届くまでに時間を要しますので、マイナ保険証をぜひご利用ください。"]
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[null,"保険証の\n記号・番号",{"$nulls":4},"－",null,null,null,"事業所名"]
[]
[null,"被保険者氏名",{"$nulls":8},"被保険者\nＴＥＬ"]
[]
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[null,"限度額証発行\n対象者氏名",{"$nulls":8},"生年月日",null,"□昭和\n□平成\n□令和",null,null,"年",null,"月",null,"日","続柄"]
[]
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[null,"使用開始日\n（予定日）",null,null,"令和",null,null,"年",null,"月",null,"日","発行事由"]
[]
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[null,"申請者\n該当に☑",null,null,"□","被保険者"]
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[{"$nulls":4},"□","ご家族",null,null,"\n\n申請者の",null,"住　所",null,"〒"]
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[{"$nulls":4},"□","事業所",{"$nulls":4},"氏　名"]
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[{"$nulls":4},"□","その他（　　　　　）",{"$nulls":4},"TEL"]
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[null,"受取の方法",null,null,"□","事業所経由"]
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[{"$nulls":4},"□","上記の申請者住所に郵送"]
[{"$nulls":5},"※住所・氏名を記載し、84円切手を貼付した返信用封筒を同封してください。"]
[{"$nulls":5},"※依頼者の身元確認書類(運転免許証、パスポート、在留カード等)のコピーを同封してください。"]
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[null,"■注意事項\n・発行する認定証の有効期間は原則申請した月の初日から次の8月末日までの最大12ヵ月間です。\n・限度額適用認定証は使用後速やかに返却することが法律で定められています。\n （滅失した場合は届出が必要です）\n・有効期限経過後、又は所得区分変更後に引き続き認定を受ける場合は、認定証を返却して再申請が必要です。\n・資格を喪失した場合や保険証記号・番号変更の場合は速やかに認定証を返却してください。\n・被保険者が市区町村民税の非課税者で所得区分を変更する場合は、非課税証明書を添付して申請ください。\n■その他\n限度額適用認定証を適用せず、お支払いが高額な負担となった場合には、自己負担限度額を超えた額が後日健保組合から「高額療養費制度」として自動的に支給されますので、限度額証の使用の有無にかかわらず最終的な自己負担は変わりません。（高額療養費は概ね窓口支払月の3ヶ月後に給付されます）"]
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[]
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[null,"健　　保　　組　　合",{"$nulls":10},"健保受付",{"$nulls":6},"事　業　所"]
[null,"決　裁",null,null,null,"処　理",{"$nulls":13},"責任者",null,"担当者"]
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[]
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[{"$nulls":22},"TGK 2024.2"]