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[{"$nulls":41},"令和　　　　年　　　　月　　　　日"]
[]
["（あて先）"]
[]
[]
[{"$nulls":22},"（医療機関等）",{"$nulls":8},"所在地"]
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[]
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[{"$nulls":31},"名称　　　　　　　　　　　　　　　　　　　　　　　　　"]
{"$rows_empty":7}
["出産費用請求報告書"]
[]
[]
[]
[]
[]
["　標記について、下記のとおり報告します。"]
[]
[]
[]
[]
["記"]
[]
[]
[]
[]
["被保険者等記号・番号",{"$nulls":17},"記号",{"$nulls":18},"番号"]
[]
[]
[]
["被保険者、世帯主又は組合員",{"$nulls":17},"氏名",null,null,null,"（フリガナ）"]
[]
[]
[]
[]
[{"$nulls":18},"住所",null,null,null,"〒",{"$nulls":6},"（フリガナ）"]
[]
[]
[]
[]
["請　求　金　額"]
[]
[]
[]
[]
["出産費用請求書(写）",{"$nulls":17},"別添のとおり"]
[]
[]
[]
[]
["出産の事実を証明する書類（写）",{"$nulls":17},"別添のとおり"]