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[null,"更新",null,"介護保険",null,null,null,null,null,"要介護更新認定・要支援更新認定",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請書"]
[]
[null,"苫小牧市長　様",null,null,null,null,"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,null,null,null,null,"申請年月日　　",null,null,null,null,null,"令和",null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[null,"被  保  険  者","介護保険\n被保険者番号",null,null,null,0,null,0,null,0,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,"医療保険","保険者名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険者番号"]
[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,null,null,null,"（",null,null,null,null,null,null,"）"]
[null,null,null,"被保険者\n記号・番号",null,null,"記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,"枝番"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日"]
[null,null,"氏名",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,"年",null,null,null,"月",null,null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　　別"]
[null,null,"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,"電話番号",null,null,null,null,null,null,null,"－",null,null,null,null,null,"－"]
[null,null,"前回の要介護認定の結果等",null,null,null,"※要介護・要支援更新認定の場合のみ",null,null,null,null,"要介護状態区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　要支援状態区分　"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有効期限　令和",null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,"から令和",null,null,"年",null,null,null,"月",null,null,null,"日"]
[null,null,null,null,null,null,"※14日以内に他自治体から転入した者のみ記入",null,null,null,null,null,"転出元自治体（市町村）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,null,null,null,null,null,null,"現在、転出元自治体に要介護・要支援認定を申請中ですか。"]
[null,null,null,null,null,null,null,null,null,null,null,null,"（既に認定結果通知を受け取っている場合は「いいえ」を選択してください。）"]
[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,"「はい」の場合、申請日　令和",null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[null,null,"過去6か月間の介護保険施設、医療機関等への入院、入所の有無",null,null,null,"　介護保険施設等の名称等・所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"期間"]
[null,null,null,null,null,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",null,null,"年",null,"月",null,"日","～",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,"　介護保険施設等の名称等・所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"期間"]
[null,null,null,null,null,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",null,null,"年",null,"月",null,"日","～",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,"　医療機関等の名称等・所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"期間"]
[null,null,null,null,null,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",null,null,"年",null,"月",null,"日","～",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,"　医療機関等の名称等・所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"期間"]
[null,null,null,null,null,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",null,null,"年",null,"月",null,"日","～",null,"年",null,"月",null,"日"]
[]
[null,"提出代行者","名称",null,"該当に〇（　",null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,"居宅介護支援事業者",null,null,null,null,null,null,null,"指定介護老人福祉施設",null,null,null,null,null,null,null,"介護老人保健施設",null,null,null,null,null,null,"介護医療院",null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,"(○)"]
[]
[null,null,"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,"電話番号",null,null,null,null,null,null,null,"-",null,null,null,"-"]
[]
[null,"主治医","主治医の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関名"]
[null,null,null,null,null,null,null,null,null,null,"（診療科",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"所在地",null,null,"〒",null,null,null,null,"－",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"筋萎縮性側索硬化症"]
[null,null,null,null,null,null,null,null,null,null,null,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,null,null,"-",null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"後縦靭帯骨化症"]
[null,"第二号被保険者（40歳から64歳の医療保険加入者）のみ記入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3,"骨折を伴う骨粗しょう症"]
[null,"特定疾病名",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,null,null,null,null,null,null,null,null,"リストから選択",null,null,null,null,null,null,null,null,4,"多系統萎縮症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5,"初老期における認知症"]
[null,"　介護サービス計画の作成等介護保険事業の適切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、主治医意見書、苫小牧市が提供を受けた介護サービス計画及び介護予防サービス計画並びに居宅サービス事業者又は介護保険施設の関係人が取得した心身の状況等の情報を、苫小牧市から地域包括支援センター、居宅介護支援事業者、居宅サービス事業者、地域密着型サービス事業者、介護保険施設、介護予防支援事業者、介護予防サービス事業者若しくは地域密着型介護予防サービス事業者の関係人、介護予防・日常生活支援総合事業を行う者、主治医意見書に係る医師又は認定調査に従事した調査員に提示する（地域支援事業として介護情報基盤経由で電子的に行う場合を含む。）ことに同意します。",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,6,"脊髄小脳変性症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7,"脊柱管狭窄症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8,"早老症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9,"糖尿病性神経障害、糖尿病性腎症及び糖尿病性網膜症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"本人氏名                                           ",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,10,"脳血管疾患"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,11,"パーキンソン病関連疾患"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,12,"閉塞性動脈硬化症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,13,"関節リウマチ"]
[null,"特 記 事 項",null,null,null,null,"  送付先変更 ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,14,"慢性閉塞性肺疾患"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,15,"両側の膝関節又は股関節に著しい変形を伴う変形性関節症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,16,"がん末期"]
[]
[null,"※市記入欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※裏面もご記入ください。"]
[null,"処理欄","介護補償給付等の受給の有無",null,null,null,null,null,null,null,null,null,null,null,"　　　　　　   (補償給付名称                                           )"]
[null,null,"受付印",null,null,null,null,null,null,"調査時に下記のとおり　　　　お願い致します",null,null,null,null,null,null,null,null,"意見書",null,null,null,"備考"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"保険証調査時回収",null,null,null,null,null,null,"新規 ・ 継続",null,null,null,"受付",null,null,null,null,null,null,null,"入力",null,null,null,null,null,null,null,"確認"]
[null,null,null,null,null,null,null,null,null,null,null,"資格者証調査時発行",null,null,null,null,null,null,"在宅 ・ 施設"]

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["認定調査連絡票（更新）"]
["　調査員が訪問を行う際の参考にさせていただきますので、下記の事項についてご記入ください。"]
["氏　名"]
["申請理由","１．更新申請の目的を記入ください。（複数回答可）"]
[null,null,"引き続き在宅サービスを利用するのため"]
[null,null,"介護施設に継続して入所するため"]
[null,null,"現在は利用していないが、今後介護サービスの利用を検討しているため"]
[null,null,"その他（　",null,null,null,null,null,null,null,null,")"]
[null,"日常生活で支障がある事（手伝ってほしいこと等）をご記入ください。（複数回答可）"]
[null,null,"家事",null,"移動",null,null,"視力低下（弱視　・　全盲）"]
[null,null,"排泄",null,"療養上の世話",null,null,"聴覚低下（難聴等）"]
[null,null,"入浴",null,"外出機会の減少",null,null,"関節痛（腰痛、膝痛含む）"]
[null,null,"買い物",null,"体力維持",null,null,"心肺機能低下による呼吸苦等"]
[null,null,"認知機能"]
[null,null,"　　　　　　　　",null,null,null,null,null,"（",null,null,"）"]
[null,null,"その他（",null,null,null,null,null,null,null,null,"）"]
["　サービス\nの\n利用状況　","過去1カ月以内に利用しているサービスについてご記入ください。（複数回答可）"]
[null,null,"訪問介護","《　　　　",null,null,"》",null," 短期入所","≪利用日　",null,"≫"]
[null,null,"訪問入浴介護","《　　　　",null,null,"》",null," 福祉用具貸与　　　　　　≪",null,"　　　　","品≫"]
[null,null,"訪問看護","《　　　　",null,null,"》",null," 福祉用具販売　　　　　　≪",null,"　　　　","品≫"]
[null,null,"訪問リハビリ","《　　　　",null,null,"》",null,"住宅改修"]
[null,null,"居宅療養\n管理指導"," ≪",null,"日/月≫　",null,null,"その他のサービス利用"]
[null,null,"通所介護","《　　　　",null,null,"》","  ≪     　　　　　　　　　　　　　　　　　　",null,null,null,"≫"]
[null,null,"通所リハビリ","《　　　　",null,null,"》"]
["家族構成",null,null,null,null,null,null,"（",null,null,null,"）"]
["通院等","最近の受診",null,null,"月",null,"日","※予定含む",null,null,"回/月"]
[null,null,"透析・・・・・・・・・・・・・・・",null,"  　　　　　　　　　　　　　　　　　　　　　　"]
[null,null,"その他定期外出・・・・・"]
[]
["調査の\n連絡先",null,"本人"]
[null,null,"申請者"]
[null,null,"その他","フリガナ"]
[null,null,null,"氏名",null,null,null,null,"続柄"]
[null,null,null,"連絡先","　　　　　　　　　"]
[null,"都合の悪い日時・電話対応可能な時間帯など"]
[]
["調査同席・聞き取りの有無\n（複数選択可）",null,"無（聞き取り不要）"]
[null,null,null,null,"フリガナ\n　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
[null,null,"無（聞き取り必要）",null,"氏名",null,null,null,null,"続柄"]
[null,null,"有",null,"連絡先"]
[null,null,null,null,"連絡先と同じであれば「同上」と記載してください"]
["留意点","調査の際に配慮することなど、事前に調査員に伝えたいことがあればご記入ください。"]
[]
[null,null,"認定調査を急ぐ（理由：",null,null,null,null,null,null,null,null,"）"]
[null,null,"退・転院予定あり　　　",null,"　　月","日","（転院先：",null,null,null,null,"）"]