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[]
["健康診断申込書"]
[]
["ﾌﾘｶﾞﾅ",{"$nulls":31},"住  所",null,"〒",{"$nulls":12},"保険証の記号"]
["事業所名称"]
["ご担当者様名",{"$nulls":11},"TEL",{"$nulls":16},"FAX",{"$nulls":5},"保険者名称\n(健康保険組合名)",{"$nulls":11},"保険証の保険者番号"]
[]
["年齢は、2026年3月31日時点の年齢です。"]
["受診者様情報に訂正がある場合は、二重線で訂正後正しい情報をご記入ください。また、今年度ご受診されない方には、二重線をお引きください。"]
[]
["★区分は、保険証を確認し記載の（本人(被保険者)・家族(被扶養者)・配偶者）に〇をつけてください。"]
[]
["希望のコース・希望オプション・第一希望日・第二希望日をご記入ください。下記①～④の□に✓をつけてください。"]
[]
["№",null,"保険証の　　番号",{"$nulls":4},"ﾌﾘｶﾞﾅ",{"$nulls":8},"性別",null,null,"生年月日",{"$nulls":10},"年齢",null,null,"★区分","コース",null,null,"希望オプション",{"$nulls":13},"第一　希望日",{"$nulls":3},"第二　希望日",{"$nulls":3},"センター記入欄"]
[{"$nulls":7},"氏名"]
[1,{"$nulls":29},{"$f":"IF(T17=\"\",\"\",BQ17)","v":""},null,null,"本人(被保険者)"]
[{"$nulls":33},"家族(被扶養者)"]
[{"$nulls":33},"配偶者"]
[2,{"$nulls":29},{"$f":"IF(T20=\"\",\"\",BQ20)","v":""},null,null,"本人(被保険者)"]
[{"$nulls":33},"家族(被扶養者)"]
[{"$nulls":33},"配偶者"]
[3,{"$nulls":29},{"$f":"IF(T23=\"\",\"\",BQ23)","v":""},null,null,"本人(被保険者)"]
[{"$nulls":33},"家族(被扶養者)"]
[{"$nulls":33},"配偶者"]
[4,{"$nulls":29},{"$f":"IF(T26=\"\",\"\",BQ26)","v":""},null,null,"本人(被保険者)"]
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[{"$nulls":33},"配偶者"]
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[{"$nulls":33},"配偶者"]
[6,{"$nulls":29},{"$f":"IF(T32=\"\",\"\",BQ32)","v":""},null,null,"本人(被保険者)"]
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[{"$nulls":33},"配偶者"]
[7,{"$nulls":29},{"$f":"IF(T35=\"\",\"\",BQ35)","v":""},null,null,"本人(被保険者)"]
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[{"$nulls":33},"配偶者"]
[8,{"$nulls":29},{"$f":"IF(T38=\"\",\"\",BQ38)","v":""},null,null,"本人(被保険者)"]
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[{"$nulls":33},"配偶者"]
[9,{"$nulls":29},{"$f":"IF(T41=\"\",\"\",BQ41)","v":""},null,null,"本人(被保険者)"]
[{"$nulls":33},"家族(被扶養者)"]
[{"$nulls":33},"配偶者"]
[10,{"$nulls":29},{"$f":"IF(T44=\"\",\"\",BQ44)","v":""},null,null,"本人(被保険者)"]
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[{"$nulls":33},"配偶者"]
["①、健診キット送付先( □上記事業所 / □個人宅 /□ その他 )",{"$nulls":35},"④-1、お支払方法( □請求 / □窓口 / □その他 )"]
[]
["　　   　その他[　　　　　　　　　　　　　　　　　　　　　　　　　　　　　]",{"$nulls":35},"             その他[　　　　　　　　　　　　　　         　　　　　　　　　　　　　　　]"]
[]
["②、健診結果送付先(  □上記事業所 / □個人宅 /□ その他 )",{"$nulls":35},"④-2、請求書送付先( □上記事業所 /  □その他 )"]
[]
["　　　   その他[　　　　　　　　　　　　　　　　　　　　　　　　　　　　　]",{"$nulls":35},"             その他[　　　　　　　　　　　　　　         　　　　　　　　　　　　　　　]"]
[]
["③、事業所控え( □必要 /□ 不要) ",{"$nulls":35},"⑤、その他　ご記入欄"]
[]
["送付先( □上記事業所 /□ その他 [　　　　　　　　　　　　　　　　　　　　　　　　]　)"]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　公益財団法人　熊本県総合保健センター　施設企画室　TEL 096-365-2323　FAX 096-365-2616"]