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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 主 （ 事 業 主 代 理 人 ） 記 入 箇 所"]
["取扱注意",null,null,null,null,null,null,"　　　健康保険被扶養者異動届（扶養するとき）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記の通り被保険者から被扶養者の届出がありましたので提出します"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　令和　　　　　年　　　　　月　　　　　日　　提出"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒　　　　　　　　－"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"健保受付",null,null,null,null,null,"健　康　保　険　組　合　　記　入　欄"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異 動 年 月 日",null,null,null,null,null,null,null,"補\n記\n事\n項"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所名称"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主氏名"]
[]
["関西電力健康保険組合　常務理事　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円","×",null,null,"＝",null,null,null,"万円",null,"/2＝",null,null,null,"　万円",null,null,"電話番号"]
[]
[]
["確認欄",null,null,null,"　　この届出は、自署または以下の要件に該当し、「確認欄」に ☑ を入れた場合は押印を省略することができます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主確認欄 （以下の内容に該当する場合は、事業主にて確認後、☑ を入れてください）"]
[null,null,null,null,"　　【要件】この届出については、①または②の要件を満たしたものです。\n　　　　　 　①申請者本人（被保険者）が作成したものです。  ②記載内容について誤りがないか申請者本人が確認しています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者との続柄に関する証明書類が省略されている者については、続柄を確認しています。（内縁関係は省略不可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"確認欄"]
[]
["被\n\n保\n\n険\n\n者\n\n記\n\n入\n\n欄","被 保 険 者 番 号",null,null,null,null,null,null,"被保険者　氏名",null,null,null,null,null,null,null,null,null,"被保険者　生年月日",null,null,null,null,null,"所　属（※任意継続被保険者は記入不要）",null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　住　民　票　住　所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭 ・ 平"," 　　年　　　月　　 日生",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒",null,null,"-"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　居　所　住　所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒",null,null,"-",null,null,null,null,null,null,null,null,"※住民票住所と同じ場合は「同上」と記入してください"]
[]
[null,"被　扶　養　者　名",null,null,null,null,null,null,null,null,null,"性\n別","続柄\n例)長男",null,"生 年 月 日",null,null,null,null,null,null,"　職業･学年　等\n例)ﾊﾟｰﾄ、高校1年生、無職",null,null,null,null,"収　入（補足 ※１）",null,null,null,null,null,null,"申　　請　　事　　由\n\n※下記申請事由の区分より選択ください。",null,null,null,null,null,null,null,null,null,null," 扶養要件を満たした日",null,null,null,null,null,null,"同居・別居の区分\n※別居の場合は別居理由を記入してください。\n　例）単身赴任、被扶養者の就学"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,"被 扶 養 者 住 所"]
[null,"フ　　リ　　ガ　　ナ",null,null,null,null,null,null,null,null,null,"被 扶 養 者 個 人 番 号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,"年　額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,"姓",null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭・平・令　\n　　　　　　　年　　　　月　　　　日",null,null,null,null,null,null,null,null,null,null,null,"給与",null,null,null,null,null,"円","区分",null,"Ａ：出生\nＢ：被保険者資格取得\nＣ：雇用保険受給終了\nＤ：退職\nＥ：結婚\nＦ：収入の減少\nＧ：別居から同居\nＨ：その他（下記余白へ記入願います）\n　　",null,null,null,null,null,null,null,null,"令",null,null,null,null,null,null,"同居 ・ 別居の区分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同 居　　　・　　　別 居　"]
[null,null,null,null,null,null,null,null,null,null,null,"住民票\n住所","〒",null,"-",null,null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,null,null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別居の場合の理由"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",null,"-",null,null,"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他\n(傷病手当、\n株配当等)",null,null,null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下欄に記載の「資格確認書」の発行確認\nＡ～Dの中から選択して記載してください。",null,null,null,"記入欄"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭・平・令　\n　　　　　　　年　　　　月　　　　日",null,null,null,null,null,null,null,null,null,null,null,"給与",null,null,null,null,null,"円","区分",null,null,null,null,null,null,null,null,null,null,"令",null,null,null,null,null,null,"同居 ・ 別居の区分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同 居　　　・　　　別 居　"]
[null,null,null,null,null,null,null,null,null,null,null,"住民票\n住所","〒",null,"-",null,null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,null,null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別居の場合の理由"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",null,"-",null,null,"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(+申請者入力!D40=\"\",\"\",申請者入力!D40)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他\n(傷病手当、\n株配当等)",null,null,null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下欄に記載の「資格確認書」の発行確認\nＡ～Dの中から選択して記載してください。",null,null,null,"記入欄"]
[null,"遡 及 理 由（届出遅延理由）申 立 書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資 格 確 認 書」 の 発 行 確 認"]
[]
[]
[null,"遡って認定すべき理由が有る場合は、以下の内容を確認し、該当する項目に ☑ をつけてください。\n※原則、健康保険組合受付日が認定日です。必ず遡及できるとは限りません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　Ａ：【発行要】マイナンバーカードを取得していない方、マイナンバーカードを返納された方\n　　Ｂ：【発行要】マイナンバーカードを保有しているが、健康保険証利用登録を行っていない方、利用登録解除を申請した方\n　　Ｃ：【発行要】マイナンバーカードの電子証明書の有効期限が切れた方\n　　Ｄ：【発行不要】マイナ保険証による受診が可能である方\n　"]
[]
[]
[]
[]
[null,null,"   申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合など）"]
[null,null,"   その他（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,{"$f":"+[1]申請者入力!D16","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,"                                          ※署名は直筆で記入願います。",null,null,null,null,null,null,null,null,null,null,null,null,"共同扶養する他保険や他組合の被保険者の年収確認"]
[null,null,null,"上記の事実に相違ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","上記被扶養者を認定するにあたって、共同で生活を支えている方（「共同扶養者」という）が存在する場合、「申請者（被保険者）」と 「共同扶養者」の双方の収入を確認しますので、「共同扶養における収入額確認表」と必要書類を添付してください。\n※該当する方：被扶養者でない配偶者や届出しようとしている被扶養者と同一世帯である他健保等の被保険者（父母、兄弟、姉妹等）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏名：　　　        　　　　　　　　　　"]
["記入にあたっての留意点（ご一読ください）"]
["〇","届出内容に誤りや虚偽の内容があった場合、被扶養者の認定そのものを取り消すことがあります。\nその間に使用された医療費は全額お返しいただきます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健保使用欄（共同扶養者の有無）",null,null,null,null,null,null,"有　・　無"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"補 足 事 項"]
["〇","個人番号については、健康保険の届出事務に関して利用するものです。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※１：収入は届出時点から向こう１年間の見込額を記入してください。収入には、非課税対象のもの（障害・遺族年金、失業給付等）も含みます。　"]
[null,"ご記入いただいた個人情報は、当該の利用目的以外には使用いたしません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和６年1２月更新"]

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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 主 （ 事 業 主 代 理 人 ） 記 入 箇 所"]
["取扱注意",null,null,null,null,null,null,"　　　健康保険被扶養者異動届（扶養するとき）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記の通り被保険者から被扶養者の届出がありましたので提出します"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　令和　　　　　年　　　　　月　　　　　日　　提出"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒　　　　　　　　－"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"健保受付",null,null,null,null,null,"健　康　保　険　組　合　　記　入　欄"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異 動 年 月 日",null,null,null,null,null,null,null,"補\n記\n事\n項"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所名称"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主氏名"]
[]
["関西電力健康保険組合　常務理事　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円","×",null,null,"＝",null,null,null,"万円",null,"/2＝",null,null,null,"　万円",null,null,"電話番号"]
[]
[]
["確認欄",null,null,null,"　　この届出は、自署または以下の要件に該当し、「確認欄」に ☑ を入れた場合は押印を省略することができます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主確認欄 （以下の内容に該当する場合は、事業主にて確認後、☑ を入れてください）"]
[null,null,null,null,"　　【要件】この届出については、①または②の要件を満たしたものです。\n　　　　　 　①申請者本人（被保険者）が作成したものです。  ②記載内容について誤りがないか申請者本人が確認しています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者との続柄に関する証明書類が省略されている者については、続柄を確認しています。（内縁関係は省略不可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"確認欄"]
[]
["被\n\n保\n\n険\n\n者\n\n記\n\n入\n\n欄","被 保 険 者 番 号",null,null,null,null,null,null,"被保険者　氏名",null,null,null,null,null,null,null,null,null,"被保険者　生年月日",null,null,null,null,null,"所　属（※任意継続被保険者は記入不要）",null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　住　民　票　住　所"]
[null,1,2,3,4,5,6,7,"関西　健太郎",null,null,null,null,null,null,null,null,null,"1995-12-02",null,null,null,null,null,"〇〇〇会社　〇〇部",null,null,null,null,null,null,null,null,null,null,null,null,"〒",987,null,"-",6543]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"沖縄県那覇市空港１"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　居　所　住　所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒",123,null,"-",4567,null,null,null,null,null,null,null,"※住民票住所と同じ場合は「同上」と記入してください"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大阪市北区中之島9-9-9"]
[null,"被　扶　養　者　名",null,null,null,null,null,null,null,null,null,"性\n別","続柄\n例)長男",null,"生 年 月 日",null,null,null,null,null,null,"　職業･学年　等\n例)ﾊﾟｰﾄ、高校1年生、無職",null,null,null,null,"収　入（補足 ※１）",null,null,null,null,null,null,"申　　請　　事　　由\n\n※下記申請事由の区分より選択ください。",null,null,null,null,null,null,null,null,null,null," 扶養要件を満たした日",null,null,null,null,null,null,"同居・別居の区分\n※別居の場合は別居理由を記入してください。\n　例）単身赴任、被扶養者の就学"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,"被 扶 養 者 住 所"]
[null,"フ　　リ　　ガ　　ナ",null,null,null,null,null,null,null,null,null,"被 扶 養 者 個 人 番 号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,"年　額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,"姓",null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,"カンサイ",null,null,null,null,"ヤスコ",null,null,null,null,"女","妻",null,"1998-01-05",null,null,null,null,null,null,"無職",null,null,null,null,"給与",null,0,null,null,null,"円","区分",null,"Ａ：出生\nＢ：被保険者資格取得\nＣ：雇用保険受給終了\nＤ：退職\nＥ：結婚\nＦ：収入の減少\nＧ：別居から同居\nＨ：その他（下記余白へ記入願います）\n　　",null,null,null,null,null,null,null,null,"Ｒ","0",6,1,2,2,5,"同居 ・ 別居の区分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同 居　　　・　　　別 居　"]
[null,"関西",null,null,null,null,"保子",null,null,null,null,"住民票\n住所","〒",{"$f":"申請者入力!D31","v":0},"-",{"$f":"申請者入力!E31","v":0},null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,0,null,null,null,"円","Ｃ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別居の場合の理由"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D32","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"単身赴任よる"]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",{"$f":"申請者入力!D33","v":0},"-",{"$f":"申請者入力!E33","v":0},{"$f":"申請者入力!G33","v":0},"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,0,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D34","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,1,2,3,4,5,6,7,8,9,1,2,3,"その他\n(傷病手当、\n株配当等)",null,0,null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下欄に記載の「資格確認書」の発行確認\nＡ～Dの中から選択して記載してください。",null,null,null,"記入欄","D"]
[null,{"$f":"+申請者入力!D47","v":0},null,null,null,null,{"$f":"+申請者入力!E47","v":0},null,null,null,null,{"$f":"+申請者入力!D49","v":0},{"$f":"+申請者入力!D50","v":0},null,{"$f":"+申請者入力!D51","v":"00:00:00"},null,null,null,null,null,null,{"$f":"+申請者入力!D52","v":0},null,null,null,null,"給与",null,{"$f":"IF(申請者入力!E57=\"\",\"\",+申請者入力!E57)","v":""},null,null,null,"円","区分",null,null,null,null,null,null,null,null,null,null,{"$f":"IF(申請者入力!D$63=\"\",\"\",IF(申請者入力!D$63>=43586,\"R\",TEXT(申請者入力!D$63,\"g\")))","v":""},null,{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"ee\"),2,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"mm\"),1,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"mm\"),2,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"dd\"),1,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"dd\"),2,1))","v":""},"同居 ・ 別居の区分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同 居　　　・　　　別 居　"]
[null,{"$f":"+申請者入力!D46","v":0},null,null,null,null,{"$f":"+申請者入力!E46","v":0},null,null,null,null,"住民票\n住所","〒",{"$f":"申請者入力!D53","v":0},"-",{"$f":"申請者入力!E53","v":0},{"$f":"申請者入力!G38","v":0},"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,{"$f":"IF(申請者入力!E58=\"\",\"\",+申請者入力!E58)","v":""},null,null,null,"円",{"$f":"申請者入力!D61","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別居の場合の理由"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D54","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",{"$f":"申請者入力!D55","v":0},"-",{"$f":"申請者入力!E55","v":0},{"$f":"申請者入力!G40","v":0},"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,{"$f":"IF(申請者入力!E59=\"\",\"\",+申請者入力!E59)","v":""},null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D56","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(+申請者入力!D40=\"\",\"\",申請者入力!D40)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D48,1,1)","v":""},{"$f":"MID(申請者入力!D48,2,1)","v":""},{"$f":"MID(申請者入力!D48,3,1)","v":""},{"$f":"MID(申請者入力!D48,4,1)","v":""},{"$f":"MID(申請者入力!D48,5,1)","v":""},{"$f":"MID(申請者入力!D48,6,1)","v":""},{"$f":"MID(申請者入力!D48,7,1)","v":""},{"$f":"MID(申請者入力!D48,8,1)","v":""},{"$f":"MID(申請者入力!D48,9,1)","v":""},{"$f":"MID(申請者入力!D48,10,1)","v":""},{"$f":"MID(申請者入力!D48,11,1)","v":""},{"$f":"MID(申請者入力!D48,12,1)","v":""},"その他\n(傷病手当、\n株配当等)",null,{"$f":"IF(申請者入力!E60=\"\",\"\",申請者入力!E60)","v":""},null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下欄に記載の「資格確認書」の発行確認\nＡ～Dの中から選択して記載してください。",null,null,null,"記入欄"]
[null,"遡 及 理 由（届出遅延理由）申 立 書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資 格 確 認 書」 の 発 行 確 認"]
[]
[]
[null,"遡って認定すべき理由が有る場合は、以下の内容を確認し、該当する項目に ☑ をつけてください。\n※原則、健康保険組合受付日が認定日です。必ず遡及できるとは限りません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　Ａ：【発行要】マイナンバーカードを取得していない方、マイナンバーカードを返納された方\n　　Ｂ：【発行要】マイナンバーカードを保有しているが、健康保険証利用登録を行っていない方、利用登録解除を申請した方\n　　Ｃ：【発行要】マイナンバーカードの電子証明書の有効期限が切れた方\n　　Ｄ：【発行不要】マイナ保険証による受診が可能である方\n　　"]
[]
[]
[]
[]
[null,null,"   申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合など）"]
[null,null,"   その他（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,{"$f":"+[1]申請者入力!D16","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,"                                          ※署名は直筆で記入願います",null,null,null,null,null,null,null,null,null,null,null,null,"共同扶養する他保険や他組合の被保険者の年収確認"]
[null,null,null,"上記の事実に相違ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","上記被扶養者を認定するにあたって、共同で生活を支えている方（「共同扶養者」という）が存在する場合、「申請者（被保険者）」と 「共同扶養者」の双方の収入を確認しますので、「共同扶養における収入額確認表」と必要書類を添付してください。\n※該当する方：被扶養者でない配偶者や届出しようとしている被扶養者と同一世帯である他健保等の被保険者（父母、兄弟、姉妹等）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏名：　　関西　健太郎　　　　　　"]
["記入にあたっての留意点（ご一読ください）"]
["〇","届出内容に誤りや虚偽の内容があった場合、被扶養者の認定そのものを取り消すことがあります。\nその間に使用された医療費は全額お返しいただきます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健保使用欄（共同扶養者の有無）",null,null,null,null,null,null,"有　・　無"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"補 足 事 項"]
["〇","個人番号については、健康保険の届出事務に関して利用するものです。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※１：収入は届出時点から向こう１年間の見込額を記入してください。収入には、非課税対象のもの（障害・遺族年金、失業給付等）も含みます。　"]
[null,"ご記入いただいた個人情報は、当該の利用目的以外には使用いたしません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和６年1２月更新"]

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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 主 （ 事 業 主 代 理 人 ） 記 入 箇 所"]
["取扱注意",null,null,null,null,null,null,"　　　健康保険被扶養者異動届（扶養するとき）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記の通り被保険者から被扶養者の届出がありましたので提出します"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　令和　　　　　年　　　　　月　　　　　日　　提出"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒　　　　　　　　－"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"健保受付",null,null,null,null,null,"健　康　保　険　組　合　　記　入　欄"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異 動 年 月 日",null,null,null,null,null,null,null,"補\n記\n事\n項"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所名称"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主氏名"]
[]
["関西電力健康保険組合　常務理事　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円","×",null,null,"＝",null,null,null,"万円",null,"/2＝",null,null,null,"　万円",null,null,"電話番号"]
[]
[]
["確認欄",null,null,null,"　　この届出は、自署または以下の要件に該当し、「確認欄」に ☑ を入れた場合は押印を省略することができます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主確認欄 （以下の内容に該当する場合は、事業主にて確認後、☑ を入れてください）"]
[null,null,null,null,"　　【要件】この届出については、①または②の要件を満たしたものです。\n　　　　　 　①申請者本人（被保険者）が作成したものです。  ②記載内容について誤りがないか申請者本人が確認しています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者との続柄に関する証明書類が省略されている者については、続柄を確認しています。（内縁関係は省略不可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"確認欄"]
[]
["被\n\n保\n\n険\n\n者\n\n記\n\n入\n\n欄","被 保 険 者 番 号",null,null,null,null,null,null,"被保険者　氏名",null,null,null,null,null,null,null,null,null,"被保険者　生年月日",null,null,null,null,null,"所　属（※任意継続被保険者は記入不要）",null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　住　民　票　住　所"]
[null,{"$f":"MID(申請者入力!$D$12,1,1)","v":""},{"$f":"MID(申請者入力!$D$12,2,1)","v":""},{"$f":"MID(申請者入力!$D$12,3,1)","v":""},{"$f":"MID(申請者入力!$D$12,4,1)","v":""},{"$f":"MID(申請者入力!$D$12,5,1)","v":""},{"$f":"MID(申請者入力!$D$12,6,1)","v":""},{"$f":"MID(申請者入力!$D$12,7,1)","v":""},{"$f":"+申請者入力!D13","v":0},null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D14","v":"00:00:00"},null,null,null,null,null,{"$f":"+申請者入力!D5&CHAR(10)&\"　\"&+申請者入力!D6","v":"\n　"},null,null,null,null,null,null,null,null,null,null,null,null,"〒",{"$f":"申請者入力!D7","v":0},null,"-",{"$f":"申請者入力!E7","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"+申請者入力!D8","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　居　所　住　所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒",{"$f":"申請者入力!D9","v":0},null,"-",{"$f":"申請者入力!E9","v":0},null,null,null,null,null,null,null,"※住民票住所と同じ場合は「同上」と記入してください"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"+申請者入力!D10","v":0}]
[null,"被　扶　養　者　名",null,null,null,null,null,null,null,null,null,"性\n別","続柄\n例)長男",null,"生 年 月 日",null,null,null,null,null,null,"　職業･学年　等\n例)ﾊﾟｰﾄ、高校1年生、無職",null,null,null,null,"収　入（補足 ※１）",null,null,null,null,null,null,"申　　請　　事　　由\n\n※下記申請事由の区分より選択ください。",null,null,null,null,null,null,null,null,null,null," 扶養要件を満たした日",null,null,null,null,null,null,"同居・別居の区分\n※別居の場合は別居理由を記入してください。\n　例）単身赴任、被扶養者の就学"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,"被 扶 養 者 住 所"]
[null,"フ　　リ　　ガ　　ナ",null,null,null,null,null,null,null,null,null,"被 扶 養 者 個 人 番 号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,"年　額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,"姓",null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,{"$f":"+申請者入力!D25","v":0},null,null,null,null,{"$f":"+申請者入力!E25","v":0},null,null,null,null,{"$f":"+申請者入力!D27","v":0},{"$f":"+申請者入力!D28","v":0},null,{"$f":"+申請者入力!D29","v":"00:00:00"},null,null,null,null,null,null,{"$f":"+申請者入力!D30","v":0},null,null,null,null,"給与",null,{"$f":"IF(申請者入力!E35=\"\",\"\",+申請者入力!E35)","v":""},null,null,null,"円","区分",null,"Ａ：出生\nＢ：被保険者資格取得\nＣ：雇用保険受給終了\nＤ：退職\nＥ：結婚\nＦ：収入の減少\nＧ：別居から同居\nＨ：その他（下記余白へ記入願います）\n　　",null,null,null,null,null,null,null,null,{"$f":"IF(申請者入力!D$41=\"\",\"\",IF(申請者入力!D$41>=43586,\"R\",TEXT(申請者入力!D$41,\"g\")))","v":""},{"$f":"IF(申請者入力!D$41=\"\",\"\",IF(AS31=\"R\",\"0\",MID(TEXT(申請者入力!D$41,\"ee\"),1,1)))","v":""},{"$f":"IF(申請者入力!D$41=\"\",\"\",MID(TEXT(申請者入力!D$41,\"ee\"),2,1))","v":""},{"$f":"IF(申請者入力!D$41=\"\",\"\",MID(TEXT(申請者入力!D$41,\"mm\"),1,1))","v":""},{"$f":"IF(申請者入力!D$41=\"\",\"\",MID(TEXT(申請者入力!D$41,\"mm\"),2,1))","v":""},{"$f":"IF(申請者入力!D$41=\"\",\"\",MID(TEXT(申請者入力!D$41,\"dd\"),1,1))","v":""},{"$f":"IF(申請者入力!D$41=\"\",\"\",MID(TEXT(申請者入力!D$41,\"dd\"),2,1))","v":""},"同居 ・ 別居の区分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D42","v":"00:00:00"}]
[null,{"$f":"+申請者入力!D24","v":0},null,null,null,null,{"$f":"+申請者入力!E24","v":0},null,null,null,null,"住民票\n住所","〒",{"$f":"申請者入力!D31","v":0},"-",{"$f":"申請者入力!E31","v":0},null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,{"$f":"IF(申請者入力!E36=\"\",\"\",+申請者入力!E36)","v":""},null,null,null,"円",{"$f":"申請者入力!D39","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別居の場合の理由"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D32","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D43","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",{"$f":"申請者入力!D33","v":0},"-",{"$f":"申請者入力!E33","v":0},{"$f":"申請者入力!G33","v":0},"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,{"$f":"IF(申請者入力!E37=\"\",\"\",+申請者入力!E37)","v":""},null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D34","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D26,1,1)","v":""},{"$f":"MID(申請者入力!D26,2,1)","v":""},{"$f":"MID(申請者入力!D26,3,1)","v":""},{"$f":"MID(申請者入力!D26,4,1)","v":""},{"$f":"MID(申請者入力!D26,5,1)","v":""},{"$f":"MID(申請者入力!D26,6,1)","v":""},{"$f":"MID(申請者入力!D26,7,1)","v":""},{"$f":"MID(申請者入力!D26,8,1)","v":""},{"$f":"MID(申請者入力!D26,9,1)","v":""},{"$f":"MID(申請者入力!D26,10,1)","v":""},{"$f":"MID(申請者入力!D26,11,1)","v":""},{"$f":"MID(申請者入力!D26,12,1)","v":""},"その他\n(傷病手当、\n株配当等)",null,{"$f":"IF(申請者入力!E38=\"\",\"\",+申請者入力!E38)","v":""},null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下欄に記載の「資格確認書」の発行確認\nＡ～Dの中から選択して記載してください。",null,null,null,"記入欄",{"$f":"申請者入力!D44","v":0}]
[null,{"$f":"+申請者入力!D47","v":0},null,null,null,null,{"$f":"+申請者入力!E47","v":0},null,null,null,null,{"$f":"+申請者入力!D49","v":0},{"$f":"+申請者入力!D50","v":0},null,{"$f":"+申請者入力!D51","v":"00:00:00"},null,null,null,null,null,null,{"$f":"+申請者入力!D52","v":0},null,null,null,null,"給与",null,{"$f":"IF(申請者入力!E57=\"\",\"\",+申請者入力!E57)","v":""},null,null,null,"円","区分",null,null,null,null,null,null,null,null,null,null,{"$f":"IF(申請者入力!D$63=\"\",\"\",IF(申請者入力!D$63>=43586,\"R\",TEXT(申請者入力!D$63,\"g\")))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",IF(AS38=\"R\",\"0\",MID(TEXT(申請者入力!D$63,\"ee\"),1,1)))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"ee\"),2,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"mm\"),1,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"mm\"),2,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"dd\"),1,1))","v":""},{"$f":"IF(申請者入力!D$63=\"\",\"\",MID(TEXT(申請者入力!D$63,\"dd\"),2,1))","v":""},"同居 ・ 別居の区分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D64","v":"00:00:00"},null,null,{"$f":"申請者入力!D64","v":"00:00:00"}]
[null,{"$f":"+申請者入力!D46","v":0},null,null,null,null,{"$f":"+申請者入力!E46","v":0},null,null,null,null,"住民票\n住所","〒",{"$f":"申請者入力!D53","v":0},"-",{"$f":"申請者入力!E53","v":0},{"$f":"申請者入力!G38","v":0},"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,{"$f":"IF(申請者入力!E58=\"\",\"\",+申請者入力!E58)","v":""},null,null,null,"円",{"$f":"申請者入力!D61","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別居の場合の理由"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D54","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D65","v":"00:00:00"}]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",{"$f":"申請者入力!D55","v":0},"-",{"$f":"申請者入力!E55","v":0},{"$f":"申請者入力!G40","v":0},"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,{"$f":"IF(申請者入力!E59=\"\",\"\",+申請者入力!E59)","v":""},null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D56","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(+申請者入力!D40=\"\",\"\",申請者入力!D40)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資格確認書」の発行確認"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D48,1,1)","v":""},{"$f":"MID(申請者入力!D48,2,1)","v":""},{"$f":"MID(申請者入力!D48,3,1)","v":""},{"$f":"MID(申請者入力!D48,4,1)","v":""},{"$f":"MID(申請者入力!D48,5,1)","v":""},{"$f":"MID(申請者入力!D48,6,1)","v":""},{"$f":"MID(申請者入力!D48,7,1)","v":""},{"$f":"MID(申請者入力!D48,8,1)","v":""},{"$f":"MID(申請者入力!D48,9,1)","v":""},{"$f":"MID(申請者入力!D48,10,1)","v":""},{"$f":"MID(申請者入力!D48,11,1)","v":""},{"$f":"MID(申請者入力!D48,12,1)","v":""},"その他\n(傷病手当、\n株配当等)",null,{"$f":"IF(申請者入力!E60=\"\",\"\",申請者入力!E60)","v":""},null,null,null,"円",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下欄に記載の「資格確認書」の発行確認\nＡ～Dの中から選択して記載してください。",null,null,null,"記入欄",{"$f":"IF(申請者入力!D66=\"\",\"\",+申請者入力!D66)","v":""}]
[null,"遡 及 理 由（届出遅延理由）申 立 書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「資 格 確 認 書」 の 発 行 確 認"]
[]
[]
[null,"遡って認定すべき理由が有る場合は、以下の内容を確認し、該当する項目に ☑ をつけてください。\n※原則、健康保険組合受付日が認定日です。必ず遡及できるとは限りません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　Ａ：【発行要】マイナンバーカードを取得していない方、マイナンバーカードを返納された方\n　　Ｂ：【発行要】マイナンバーカードを保有しているが、健康保険証利用登録を行っていない方、利用登録解除を申請した方\n　　Ｃ：【発行要】マイナンバーカードの電子証明書の有効期限が切れた方\n　　Ｄ：【発行不要】マイナ保険証による受診が可能である方\n　"]
[]
[]
[]
[]
[null,null,"   申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合など）"]
[null,null,"   その他（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,{"$f":"+[1]申請者入力!D16","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,"                                          ※署名は直筆で記入願います。",null,null,null,null,null,null,null,null,null,null,null,null,"共同扶養する他保険や他組合の被保険者の年収確認"]
[null,null,null,"上記の事実に相違ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","上記被扶養者を認定するにあたって、共同で生活を支えている方（「共同扶養者」という）が存在する場合、「申請者（被保険者）」と 「共同扶養者」の双方の収入を確認しますので、「共同扶養における収入額確認表」と必要書類を添付してください。\n※該当する方：被扶養者でない配偶者や届出しようとしている被扶養者と同一世帯である他健保等の被保険者（父母、兄弟、姉妹等）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏名：　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["記入にあたっての留意点（ご一読ください）"]
["〇","届出内容に誤りや虚偽の内容があった場合、被扶養者の認定そのものを取り消すことがあります。\nその間に使用された医療費は全額お返しいただきます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健保使用欄（共同扶養者の有無）",null,null,null,null,null,null,"有　・　無"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"補 足 事 項"]
["〇","個人番号については、健康保険の届出事務に関して利用するものです。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※１：収入は届出時点から向こう１年間の見込額を記入してください。収入には、非課税対象のもの（障害・遺族年金、失業給付等）も含みます。　"]
[null,"ご記入いただいた個人情報は、当該の利用目的以外には使用いたしません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和６年1２月更新"]

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["入力シート"]
[null,null,"１．下記項目（黄色）に入力してください。\n２．入力後、右のボタンをクリックし、届出内容を確認後印刷し、\n　　捺印（用紙中段付近と左下の２箇所）の上、担当箇所へご提出ください。"]
[]
["１．被保険者・共同扶養者情報入力"]
[null,"会社名\n(選択してください)",null,null,null,"リスト選択",null,{"$f":"IF(VLOOKUP(D5,リスト!$B$75:$F$111,5,0)=1,\"\",1)","v":{"$error":"#N/A"}}]
[null,"所　　属",null,null,null,"入力"]
[null,null,"住民票住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）",null,null,"入力"]
[null,null,"住民票住所\n",null,null,"入力"]
[null,null,"居所住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）",null,null,"入力"]
[null,null,"居所住所\n※住民票住所と同じ場合は同上とご記入下さい\n",null,null,"入力"]
[]
[null,"被保険者","被保険者番号",null,null,"入力"]
[null,null,"氏名",null,null,"入力"]
[null,null,"生年月日",null,"入力例：「1970/3/3」","入力"]
[]
[]
[]
[]
[]
[]
[]
[]
["2．被扶養者情報入力"]
[null,"被扶養者１","被扶養者氏名（姓・名）",null,null,"入力"]
[null,null,"被扶養者カナ（セイ・メイ）",null,null,"入力"]
[null,null,"個人番号",null,"入力例：１２桁「000123456789」","入力"]
[null,null,"性別",null,"入力例：「男」、「女」","入力"]
[null,null,"続柄",null,"入力例：「長男」、「長女」等","入力"]
[null,null,"生年月日",null,"入力例：「2018/5/1」","入力"]
[null,null,"職業",null,"入力例：「ﾊﾟｰﾄ」、「高校1年生」、\n「無職」等","入力"]
[null,null,"住民票住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"住民票住所\n※被保険者の住民票住所と別の場合に入力"]
[null,null,"居所住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"居所住所\n※被保険者の居所住所と別の場合に入力"]
[null,null,"収入（年額）\n※円単位で入力してください。\n※「O」円の場合は、「０」と入力","給与",null,"入力"]
[null,null,null,"年金",null,"入力"]
[null,null,null,"事業",null,"入力"]
[null,null,null,"その他\n(傷病手当金・株式配当等）",null,"入力"]
[null,null,"申請事由",null,null,"リスト選択","→"]
[null,null,null,null,{"$f":"IF($D$39=\"Ｈ\",\"←具体的理由を入力してください\",\"←入力不要\")","v":"←入力不要"}]
[null,null,"扶養要件を満たした日",null,"入力例：令和元年５月１日の場合→\n７桁2019/5/1」を入力ください。\n（決まっていない場合は、ブランク）","入力"]
[null,null,"同居区分",null,null,"リスト選択"]
[null,null,"別居理由",null,null,"リスト選択"]
[null,null,"資格確認書の発行要否",null,null,"リスト選択"]
[]
[null,"被扶養者2","被扶養者氏名（姓・名）",null,null,"入力"]
[null,null,"被扶養者カナ（セイ・メイ）",null,null,"入力"]
[null,null,"個人番号",null,"入力例：１２桁「000123456789」","入力"]
[null,null,"性別",null,"入力例：「男」、「女」","リスト選択"]
[null,null,"続柄",null,"入力例：「長男」、「長女」等","入力"]
[null,null,"生年月日",null,"入力例：「2018/5/1」","入力"]
[null,null,"職業",null,"入力例：「無職」、「アルバイト」等","入力"]
[null,null,"住民票住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"住民票住所\n※被保険者の住民票住所と別の場合に入力"]
[null,null,"居所住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"居所住所\n※被保険者の居所住所と別の場合に入力"]
[null,null,"収入（年額）\n※円単位で入力してください。\n※「O」円の場合は、「０」と入力","給与",null,"入力"]
[null,null,null,"年金",null,"入力"]
[null,null,null,"事業",null,"入力"]
[null,null,null,"その他\n(傷病手当金・株式配当等）",null,"入力"]
[null,null,"申請事由",null,{"$f":"IF(D61=\"\",\"\",VLOOKUP(D61,リスト!$B$32:$D$39,2,0))","v":""},"リスト選択","→"]
[null,null,null,null,{"$f":"IF($D$61=\"Ｈ\",\"←被扶養者１として入力された内容を表示します。\",\"←入力不要\")","v":"←入力不要"}]
[null,null,"扶養要件を満たした日",null,"入力例：令和元年５月１日の場合→\n７桁2019/5/1」を入力ください。\n（決まっていない場合は、ブランク）","入力"]
[null,null,"同居区分",null,null,"リスト選択"]
[null,null,"別居理由",null,null,"リスト選択"]
[null,null,"資格確認書の発行要否",null,null,"リスト選択"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"→"]

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[]
[null,"会社名",null,null,null,null,null,"別居理由",null,null,"続柄一覧"]
[null,"001.関西電力株式会社",null,null,null,1,null,"被保険者が単身赴任のため",null,null,"名称","名称","名称","名称","名称","名称","名称"]
[null,"002.○○○",null,null,null,0,null,"被扶養者の就学による別居",null,null,"夫","長男","長女","孫男","祖父","兄","叔父"]
[null,null,null,null,null,null,null,"被扶養者が施設に入居のため",null,null,"妻","二男","二女","孫女","祖母","弟","叔母"]
[null,null,null,null,null,null,null,"里帰り出産のため",null,null,"内夫","三男","三女","孫配偶者男","曽祖父","義兄","甥"]
[null,"性別１",null,null,null,null,null,"その他",null,null,"内妻","四男","四女","孫配偶者女","曽祖母","義弟","姪"]
[null,"男",{"$f":"IF(申請者入力!D27=\"男\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,"五男","五女","父","義祖父","姉","伯父"]
[null,"女",{"$f":"IF(申請者入力!D27=\"女\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,"六男","六女","母","義祖母","妹","伯母"]
[null,null,null,null,null,null,null,null,null,null,null,"七男","七女","養父","養祖父","義姉","他親（男）"]
[null,"性別２",null,null,null,null,null,null,null,null,null,"養子","養女","養母","養祖母","義妹","他親（女）"]
[null,"男",{"$f":"IF(申請者入力!D49=\"男\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,"子夫","子養","義父"]
[null,"女",{"$f":"IF(申請者入力!D49=\"女\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,null,null,"義母"]
[]
[null,"性別３"]
[null,"男",{"$f":"IF(申請者入力!D71=\"男\",\"○\",\"\")","v":""},null,null,null,null,"資格確認書の発行理由"]
[null,"女",{"$f":"IF(申請者入力!D71=\"女\",\"○\",\"\")","v":""},null,null,null,null,"　Ａ","マイナンバーカードを取得していない方、マイナンバーカードを返納された方"]
[null,null,null,null,null,null,null,"　Ｂ","マイナンバーカードを保有しているが、健康保険証利用登録を行っていない方、利用登録解除を申請した方"]
[null,null,null,null,null,null,null,"　Ｃ","マイナンバーカードの電子証明書の有効期限が切れた方"]
[null,null,null,null,null,null,null,"　Ｄ","保険診療の際に介護が必要であり、介護者等に「資格確認書」を預ける必要があるため"]
[null,"申請事由１"]
[null,"Ａ","出生"]
[null,"Ｂ","被保険者資格取得"]
[null,"Ｃ","雇用保険受給終了"]
[null,"Ｄ","退職"]
[null,"Ｅ","結婚"]
[null,"Ｆ","収入減少"]
[null,"Ｇ","別居から同居によるもの"]
[null,"Ｈ","その他（具体的理由を下記に記載）"]
[]
[null,"申請事由２"]
[null,"Ａ","出生"]
[null,"Ｂ","被保険者資格取得"]
[null,"Ｃ","雇用保険受給終了"]
[null,"Ｄ","退職"]
[null,"Ｅ","結婚"]
[null,"Ｆ","収入減少"]
[null,"Ｇ","別居から同居によるもの"]
[null,"Ｈ","その他（扶養者１に記載）"]
[]
[null,"申請事由３"]
[null,"Ａ","出生"]
[null,"Ｂ","被保険者資格取得"]
[null,"Ｃ","雇用保険受給終了"]
[null,"Ｄ","退職"]
[null,"Ｅ","結婚"]
[null,"Ｆ","収入減少"]
[null,"Ｇ","別居から同居によるもの"]
[null,"Ｈ","その他（扶養者１に記載）"]
[]
[]
[]
[null,"同居区分１"]
[null,"同居",{"$f":"IF(申請者入力!D42=\"同居\",\"○\",\"\")","v":""}]
[null,"別居",{"$f":"IF(申請者入力!D42=\"別居\",\"○\",\"\")","v":""}]
[]
[null,"同居区分２"]
[null,"同居",{"$f":"IF(申請者入力!D64=\"同居\",\"○\",\"\")","v":""}]
[null,"別居",{"$f":"IF(申請者入力!D64=\"別居\",\"○\",\"\")","v":""}]
[]
[null,"同居区分３"]
[null,"同居",{"$f":"IF(申請者入力!D84=\"同居\",\"○\",\"\")","v":""}]
[null,"別居",{"$f":"IF(申請者入力!D84=\"別居\",\"○\",\"\")","v":""}]
[]
[]
[null,"申立申告"]
[null,"申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）",{"$f":"IF(申請者入力!D15=\"申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）\",\"Ｖ\",\"\")","v":""}]
[null,"その他（下記余白へ記入して下さい。）",{"$f":"IF(申請者入力!D15=\"その他（下記余白へ記入して下さい。）\",\"Ｖ\",\"\")","v":""}]
[]
[]
[]
[]
[]
[null,"会社リスト",null,null,null,"1：会社で記入、２：本人記入、他"]
[null,"501．関西電力株式会社",null,null,null,2]
[null,"502．関西電力送配電株式会社",null,null,null,2]
[null,"13． かんでんＥハウス（株）",null,null,null,2]
[null,"18．（株）関電エネルギーソリューション",null,null,null,2]
[null,"19．（株）関電オフィスワーク",null,null,null,2]
[null,"31．関西電力健康保険組合",null,null,null,2]
[null,"32.関電不動産投資顧問(株)",null,null,null,2]
[null,"33．関電ガスサポート(株)",null,null,null,2]
[null,"34.関電アセットマネジメント㈱",null,null,null,2]
[null,"35．Ｎｅｘｔ　Ｐｏｗｅｒ㈱",null,null,null,2]
[null,"37．関電コミュニティ（株）",null,null,null,2]
[null,"40．（株）かんでんＣＳフォーラム",null,null,null,2]
[null,"41．（株）関西メディカルネット",null,null,null,2]
[null,"44．ゲキダンイイノ合同会社",null,null,null,2]
[null,"46．（株）原子力エンジニアリング",null,null,null,2]
[null,"47.関西電子ビーム",null,null,null,2]
[null,"48．関電ファシリティーズ㈱",null,null,null,2]
[null,"49．関電プロパティーズ㈱",null,null,null,2]
[null,"61．関電プラント（株）",null,null,null,2]
[null,"62．（株）かんでんエンジニアリング",null,null,null,2]
[null,"63．（株）ＫＡＮＳＯテクノス",null,null,null,2]
[null,"67．（株）エネゲート",null,null,null,2]
[null,"69．（株）日本ネットワークサポート",null,null,null,2]
[null,"71．（株）関電アメニックス",null,null,null,2]
[null,"72．関電不動産開発（株）",null,null,null,2]
[null,"74．黒部峡谷鉄道（株）",null,null,null,2]
[null,"75．（株）ニュージェック",null,null,null,2]
[null,"76．（株）関電システムズ",null,null,null,2]
[null,"77．（株）関電Ｌ＆Ａ",null,null,null,2]
[null,"80．（株）関電パワーテック",null,null,null,2]
[null,"82．（財）関西電気保安協会",null,null,null,2]
[null,"84．関西電力労働組合",null,null,null,2]
[null,"87．関電サービス（株）",null,null,null,2]
[null,"90．（株）オプテージ",null,null,null,2]
[null,"93．（株）原子力安全ｼｽﾃﾑ研究所",null,null,null,2]
[null,"95．（株）かんでんエルハート",null,null,null,2]
[null,"98．関西電力福祉会",null,null,null,2]