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[]
[]
[null,"様式第７号（第５条関係）"]
[null,"介護保険【要介護認定・要支援認定】申請書"]
[null,"　人吉市長　　様",null,null,null,null,null,null,"□新規申請　□変更申請　□更新（    ）月　□転入継続"]
["　次のとおり申請します。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請日",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
["被保険者（認定を受ける）","介護保険\n被保険者番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個　人　番　号"]
[null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生　年　月　日",null,null,null,"明・大・昭",null,null,null,"　　年　　　　　月　　　　　日　"]
[null,"氏　　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　　別",null,null,null,"男　・　女"]
[null,"医療保険","保　険　者　名",null,null,null,null,null,null,null,null,null,null,null,null,null,"保　険　者　番　号"]
[null,null,"被保険者証記号",null,null,null,null,null,null,null,null,null,null,null,null,null,"番　号　",null,null,null,null,null,null,null,null,null,null,"枝　番"]
[null,"住　　所",null,null,null,null,"〒",null,null,"－",null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,"（",null,null,null,"）"]
[]
[null,"　変更申請の理由   (具体的に記載)"]
[null,"前回の認定区分",null,null,null,null,"□なし　□要支援１　□要支援２　□要介護１　□要介護２　□要介護３　□要介護４　□要介護５"]
[null,"認定有効期間",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,"～",null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,"※14日以内に\n他市町村から転入\nした場合のみ記入",null,null,null,null,"人吉市へ転入して14日以内の方は下記を御記入ください。"]
[null,null,null,null,null,null,"前市町村〔　　　　　　　〕で認定あり・認定なし・認定申請中である。"]
[]
[]
["主治医","医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師氏名"]
[]
[null,"所在地",null,null,null,null,"〒",null,null,"－",null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,"（",null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□入院中"]
[null,"最終受診日※",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","次回受診予定日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
["※入院中の方は診察日の記入は不要です。"]
["第２号被保険者（40歳から64歳までの医療保険加入者）の方は御記入ください。（医療保険証のコピー添付）"]
["特定疾病名"]
[]
[]
["提出者","家族または提出代行者  ※本人の場合は記入不要",null,null,null,null,null,null,null,null,null,null,null,null,null,"(提出代行する際は事業所印を押してください。)"]
[null,null,"□地域包括支援センター　□居宅介護支援事業者　□指定介護老人福祉施設　□介護老人保健施設"]
[null,null,"□指定介護療養型医療施設　□介護医療院　□家族　続柄（　　　　　　）"]
[null,null,"氏　名（名称）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"㊞",null,"担当者名"]
[null,null,null,null,null,"〒",null,null,"－",null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,"（",null,null,"）"]
[null,null,"住　所（所在地）"]
[]
["送付先","認定結果通知に関すること　※被保険者以外への送付を希望する場合は記入。提出後の送付先変更は対応できかねます。"]
[]
[null,"　　□提出者　　　　　　　　　　　　"]
[null,"　　□その他（　氏名　　　　　　　　　　　　　　　　　　　本人との関係　　　　　　　　　　　）　　　　　　　　"]
[null,null,null,null,null,"〒",null,null,"－",null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,"（",null,null,"）"]
[null,null,"住　所（所在地）"]
[]
["同意書","介護サービス計画の作成等介護保険事業の適正な運営のために必要があるときは、要介護認定・要支援認定にかかる調査内容、介護認定審査会による判定結果・意見及び主治医意見書を、地域包括支援センター、居宅介護支援事業所居宅サービス事業所、若しくは介護保険施設の関係人、主治医意見書を記載した医師又は認定調査に従事した調査員に提示することに同意します。また私は、認定更新申請から３０日以内に更新の認定がされない場合でも、現在の認定の有効期間内に認定の結果が通知されるのであれば、認定延期通知の省略に同意します。"]
[]
[]
[]
[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,"(","続柄",null,null,null,"）"]
[null,"被保険者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"代筆者氏名"]
[]
[null,"(本人自署）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付印"]
["市記入欄",null,"訪問調査日\n　　　　　　　　　　　　　　　　　月　　　　　　　日　\n　\n　　　　 　　　（　　　　　　　　時　　　　　　　分　）",null,null,null,null,null,null,null,null,null,null,null,null,"受付番号",null,null,null,null,"調査",null,"入力"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険料未納",null,null,null,null,"意見書発送"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□なし　□あり"]
[]
["訪問調査について"]
["①訪問調査日程調整の連絡先    平日の日中に連絡を取ることができる連絡先を御記入ください。"]
[null,"□本人（被保険者）",null,null,null,null,null,null,null,null,"氏　名",null,null,null,null,null,null,null,null,null,null,"申請者との関係（　　　　　　　）"]
[null,"□提出者",null,null,null,null,null,null,null,null,"住　所"]
[null,"□その他（右欄に記入）⇒",null,null,null,null,null,null,null,null,"TEL又は携帯",null,null,null,"　",null,null,null,"（",null,null,"）"]
["②調査の立ち合い　　          認定調査時に立ち合いを希望されるかどうか御記入ください。"]
[null,"□立ち合い者なし",null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,"申請者との関係（　　　　　　　）"]
[null,"□上記日程調整者と同じ",null,null,null,null,null,null,null,null,"住所"]
[null,"□その他（右欄に記入）⇒",null,null,null,null,null,null,null,null,"TEL又は携帯",null,null,null,"　",null,null,null,"（",null,null,"）"]
["③訪問調査希望日　　月～金曜日のうちで調査に伺うのに都合の悪い曜日に×を御記入ください。"]
[null,null,null,null,null,null,null,"月",null,null,null,null,"火",null,null,null,null,"水",null,null,null,null,"木",null,null,null,null,"金"]
["午　前"]
["午　後"]
["　　　　※基本的な調査開始時間は、午前９時、10時、午後1時30分からとなります。"]
["④訪問調査場所　　本人が現在いらっしゃる場所について御記入ください。"]
[null,"□自宅（住民登録地）"]
[null,"□入院・入所先　　ここにチェックされた方は、⑤について御記入ください。"]
[null,"□その他　　（　　　　　　　　　　）"]
[null,"　住所　　　〒　　　-　　　",null,null,"〒",null,null,"－"]
[]
["⑤病院入院中、介護施設等入所中の方　現在入院中または入所中の施設について御記入ください。"]
["入院・入所日",null,null,null,null,null,"　　　　　　　　　",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"か","ら","入　","院　",null,"・","入","所　","中"]
["病院・施設名"]
["　所　在　地　\n（市外の場合のみ記入）　　",null,null,null,null,null,"〒",null,null,"－",null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,"（",null,null,"）"]
[]
[]
[]
["備考欄",null,null,"◇調査時に配慮すべき点を記入してください。"]
["※　調査員が訪問に伺う際の参考にさせていただきますので、下記の質問事項にお答えください。"]
[null,"    生 活 形 態",null,null,null,null,null,null,null,null,"　□家族と同居　□高齢者のみ世帯　□独り暮らし　□入院・入所"]
[null,"    身障手帳等",null,null,null,null,null,null,null,null,"　□なし　　　　□あり（　　　　　　　　手帳　　　　　　級　）"]
[null,"身体等の状況","治療中の病気",null,null,null,null,null,null,null,"　□なし　　　　□あり（　　　　　　　　　　　　　　　　）"]
[null,null,"日常会話の支障",null,null,null,null,null,null,null,"　□なし　　　　□あり"]
[null,null,"認 知 症 状",null,null,null,null,null,null,null,"　□なし　　　　□あり（　　　　　　　　　　　　　　　　）"]
[null,null,"身体の動き",null,null,null,null,null,null,null,"　□ほとんどベッド（布団）での生活　　□部屋の中での生活"]
[null,null,null,null,null,null,null,null,null,null,"　□外出できる　（　　□　独りで　　　□介助が必要　　）"]
[null," 現在利用しているサービス",null,null,null,null,null,null,null,null,"　□なし　　□あり（下欄に利用しているサービスを御記入ください。）"]
[]
[]
[null,null,"月曜",null,null,null,"火曜",null,null,null,"水曜",null,null,null,"木曜",null,null,null,"金曜",null,null,null,"土曜",null,null,null,"日曜"]
[]
[]
[]
[null,"　※　現在、訪問看護サービスを利用している　（　はい　　・　　いいえ　　）"]