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[{"$nulls":16},"(提出年月日)"]
[{"$nulls":14},"年　　月　　日"]
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[null,"（あて先）玉城町長"]
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[{"$nulls":8},"事業所番号"]
[{"$nulls":8},"事業所名称"]
[{"$nulls":8},"事業所の所在地及び連絡先"]
[{"$nulls":13},"TEL"]
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[null,"介護給付費明細書過誤返戻依頼書"]
[null,"　下記の明細書は、申立理由のとおり記載誤りがありましたので、過誤返戻処理をお願いいたします。"]
[null,"サービス提供年月分","令和　 　年　　　月分",{"$nulls":9},"※サービスを提供した月を記入。"]
[null,"請求月","令和　　　 年　　　月",{"$nulls":9},"※国保連合会に請求した月を記入。"]
[null,"フリガナ"]
[null,"被保険者氏名"]
[null,"被保険者番号"]
[null,"サービス提供様式　　(該当様式をチェックしてください)"]
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[null,null,"□","様式2の2",null,null,"□","様式4の2",null,null,"□","様式6の2",null,null,"□","様式6の6",null,null,"□","様式8"]
[null,null,"□","様式3",null,null,"□","様式5",null,null,"□","様式6の3",null,null,"□","様式6の7",null,null,"□","様式9"]
[null,null,"□","様式3の2",null,null,"□","様式5の2",null,null,"□","様式6の4",null,null,"□","様式7",null,null,"□","様式10"]
[]
[null,"申立理由"]
[null,"※この依頼書は被保険者毎に作成してください。"]
[null,"※過誤返戻依頼されました介護給付費明細書は「介護給付費過誤決定通知書」に記載されます。再請"]
[null,"　求されます場合は、過誤返戻処理が完了している事を必ずご確認のうえ、月遅分とあわせて当月分"]
[null,"　とは別の請求書により再請求を行ってください。"]

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[{"$nulls":16},"(提出年月日)"]
[{"$nulls":14},"　　年　　月　　日"]
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[null,"（あて先）　　　　　長"]
[]
[{"$nulls":8},"事業所番号"]
[{"$nulls":8},"事業所名称"]
[{"$nulls":8},"事業所の所在地及び連絡先"]
[{"$nulls":13},"TEL"]
[]
[null,"介護給付費明細書同月過誤返戻依頼書"]
[null,"　下記の明細書は、申立理由のとおり記載誤りがありましたので、同月過誤返戻処理をお願いいたします。"]
[null,"サービス提供年月分"," 　　年　　月分",{"$nulls":9},"※サービスを提供した月を記入。"]
[null,"請求月","　 年　　月",{"$nulls":9},"※国保連合会に請求した月を記入。"]
[null,"フリガナ"]
[null,"被保険者氏名"]
[null,"被保険者番号"]
[null,"サービス提供様式　　(該当様式をチェックしてください)"]
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[]
[null,"申立理由"]
[null,"※この依頼書は被保険者毎に作成してください。"]
[null,"※同月過誤処理は同月内において取り下げの過誤処理と介護給付費の再請求処理を同時に行いますので、"]
[null,"　保険者と調整の上、処理月の5日までに当月分とは別の請求書により再請求を行ってください。"]

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[null,"様式第2","訪問通所系"]
[null,null,"訪問介護・訪問入浴・訪問看護・訪問リハ・通所介護・通所リハ・福祉用具貸与・居宅療養管理指導"]
[null,null,"夜間対応型訪問介護・小規模多機能型居宅介護・認知症対応型通所介護"]
[null,"様式第2の2","訪問通所系"]
[null,null,"介護予防訪問介護・介護予防訪問入浴・介護予防訪問看護・介護予防訪問リハ・介護予防通所介護・介護予防通所リハ・介護予防福祉用具貸与・介護予防居宅療養管理指導"]
[null,null,"介護予防小規模多機能型居宅介護・介護予防認知症対応型通所介護"]
[null,"様式第3","短期入所生活介護"]
[null,"様式第3の2","介護予防短期入所生活介護"]
[null,"様式第4","短期入所療養介護（老健）"]
[null,"様式第4の2","介護予防短期入所療養介護（老健）"]
[null,"様式第5","短期入所療養介護（病院等）"]
[null,"様式第5の2","介護予防短期入所療養介護（病院等）"]
[null,"様式第6","認知症対応型共同生活介護（短期利用以外）"]
[null,"様式第6の2","介護予防認知症対応型共同生活介護（短期利用以外）"]
[null,"様式第6の3","特定施設入居者生活介護・地域密着型特定施設入居者生活介護（短期利用以外）"]
[null,"様式第6の4","介護予防特定施設入居者生活介護"]
[null,"様式第6の5","認知症対応型共同生活介護（短期利用）"]
[null,"様式第6の6","介護予防認知症対応型共同生活介護（短期利用）"]
[null,"様式第6の7","特定施設入居者生活介護・地域密着型特定施設入居者生活介護（短期利用）"]
[null,"様式第7","居宅介護支援"]
[null,"様式第7の2","介護予防支援"]
[null,"様式第8","特養入所・地域密着型特養入所"]
[null,"様式第9","老健入所"]
[null,"様式第10","療養入院"]