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["（様式第6号）"]
[null,"　　 令和","年",null,null,"月分柔道整復施術療養費支給申請総括票（Ⅰ）"]
[]
[null,"保険者名","種　　別",null,"請　　　　　　　　　　　　　　　求",null,null,"長野県後期高齢者医療広域連合"]
["（注）本票は全請求書の上部に必ず添付し翌月７日迄に所定の審査場所へ提出すること。",null,null,null,"件　　数","実日数","金額"]
[null,null,"国保"]
[null,null,"退職",null,null,null,null,"請　　　　　　　　　　　　　　　求"]
[null,null,null,null,null,null,null,"件　　数","実日数","金額"]
[null,null,"国保"]
[null,null,"退職"]
[]
[null,null,"国保"]
[null,null,"退職"]
[]
[null,null,"国保"]
[null,null,"退職"]
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[null,null,"国保"]
[null,null,"退職"]
[]
[null,null,"国保"]
[null,null,"退職"]
[]
[null,null,"国保"]
[null,null,"退職"]
[]
[null,null,"国保"]
[null,null,"退職"]
[]
[null,null,"国保"]
[null,null,"退職",null,null,null,null,null,null,"審査委員"]
[null,null,null,null,null,null,null,null,null,"印"]
[null,"小　　　　計",null,null,null,null,null,null,null,"担当者"]
[null,"合　　　　計",null,null,null,null,null,null,null,"検印"]
[null,"一件当り",null,null,null,null,"柔道整復師"]
[null,"平均金額",null,null,null,"円","住所・氏名"]
[null,"柔整師No."]