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[null,"健康保険限度額適用認定証 滅失届"]
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[null,"届出年月日",null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
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[null,"記号・番号\n（保険証左上に記載）",{"$nulls":10},"－",{"$nulls":6},"事業所名"]
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[null,"被保険者氏名",{"$nulls":21},"被保険者\nTEL"]
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[]
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[null,"下記認定対象者に発行された健康保険限度額認定証を滅失いたしました。なお、この認定証を発見したときは、ただちに返納いたします。"]
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[null,"届出区分"]
[{"$nulls":12},"（",{"$nulls":23},"）"]
[null,"対象者者氏名",{"$nulls":17},"生年\n月日",{"$nulls":6},"年",null,null,"月",null,null,"日","続　柄"]
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[null,"再交付の希望について",{"$nulls":6},"　　　再交付を希望する　\n※滅失・毀損等により再交付を受ける場合は、再交付料として1,000円/枚 徴収いたします。","再交付を希望する　\n※　再発行が必要な場合は、改めて　「健康保険限度額適用認定申請書」　を提出してください。"]
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[{"$nulls":9},"再交付を希望しない"]