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["過   誤   申   立   依   頼   書"]
["(　通常過誤　・　同月過誤　）"]
[{"$nulls":20},"         　年　      月　      日"]
[]
[]
[null,"青　木　村　長   殿"]
[]
[]
["事業所番号",{"$nulls":13},"事業所名"]
[]
["担当者氏名",{"$nulls":13},"電話番号"]
[]
[]
["下 記 に よ り 過 誤 申 立 を 依 頼 し ま す"]
[]
["被保険者番号",{"$nulls":13}," 氏             名"]
[]
["証 記 載 番 号",{"$nulls":6},2,0,3,4,9,7,null,"申 立 年 月 日"]
[]
["請求明細書様式番号",{"$nulls":6},"様式第",{"$nulls":6},"サービス提供年月"]
[]
["申 立 事 由 （ 理 由 ）"]
["　１　申し立ての具体的な内容"]
[]
[]
[]
[]
[]
["　２　変更となる単位数等"]
[null,"サービス内容",{"$nulls":5},"サービスコード",{"$nulls":5},"単位数",null,null,"回数日数",null,"サービス単位数",null,null,null,"公費回数",null,"公費対象単位数"]
["変更前"]
[]
[]
[]
["変更後"]
[]
[]
[]
[]
["　３　変更となる特定入所者介護サービス費等"]
[null,null,"サービスコード",null,null,"費用額（日額）",null,null,null,"負担限度額（日額）",null,null,null,"日数",null,"費用額（月額）",null,null,null,"負担限度額（月額）",null,null,null,"保険請求額(月額)"]
["変更前"]
[]
["変更後"]
[]
[]
["保険者",null,null,"０１  台帳誤りの過誤調整",{"$nulls":7},"０２  請求誤りの実績取下げ",{"$nulls":7},"０３  その他の実績取下げ"]
["記入欄"]
[]
["　","※通常過誤は毎月１５日までに、同月過誤は毎月５日までに提出をお願いします。"]
[]
["  問い合わせ先"]
["  〒３８６－１６０１      長野県小県郡青木村大字田沢１１１"]
[null,"青木村　住民福祉課　地域包括支援センター係           電話番号  ０２６８－４９－０１１１"]