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["健康保険 証明書等発行(再発行)依頼書"]
[]
[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},"生年月日",null,"□昭和\n□平成",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,"　発行(再発行)を希望する該当書類に☑"]
[]
[null,"□","１．被保険者資格喪失・被扶養者削除証明書"]
[]
[null,null,"□","世帯全員分"]
[null,null,"□","以下の対象者"]
[null,null,null,"①","氏　　　名",{"$nulls":5},"続　柄",null,null,"③","氏　　　名",{"$nulls":5},"続　柄"]
[]
[]
[null,null,null,"②","氏　　　名",{"$nulls":5},"続　柄",null,null,"④","氏　　　名",{"$nulls":5},"続　柄"]
[]
[]
[]
[null,"□","２．給付金支給決定通知書"]
[]
[null,null,"期　間",null,null,"令和",null,"年",null,"月","～","令和",null,"年",null,"月","分"]
[]
[null,null,"　　　　　　　　※①は受診期間、②～⑤は請求期間（不明な場合はおおよその期間で構いません）"]
[null,null,"□","①高額療養費・付加金"]
[null,null,"□","②傷病手当金・付加金"]
[null,null,"□","③出産手当金"]
[null,null,"□","④出産育児一時金"]
[null,null,"□","⑤埋葬料(費)"]
[]
[null,"□","３．その他　　書類の名称："]
[]
[null,null,"  ※「医療費のお知らせ」は再発行できません。（マイナポータルで診療・薬剤・医療費・健診情報が確認できます）"]
[null,"発行の理由"]
[]
[]
[null,"受取の方法",null,null,"□","事業所経由"]
[]
[{"$nulls":4},"□","以下の依頼者住所に郵送"]
[{"$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。"]
[{"$nulls":5},"※依頼者の身元確認書類(運転免許証、パスポート、在留カード等)のコピーを同封してください。"]
[null,"　上記のとおり書類の発行(再発行)を依頼します。"]
[]
[null,null,"令和",null,"年",null,"月",null,"日",null,"住　所",null,"〒"]
[{"$nulls":19},"被保険者との続柄"]
[{"$nulls":10},"氏　名",{"$nulls":8},"（",null,null,"  ）"]
[]
[{"$nulls":10},"TEL"]
[]
[null,"健　　保　　組　　合",{"$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"]
[]
[]
[]
[{"$nulls":22},"TGK 2023.4"]