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{"sheet":"利用料金確認書","index":0,"n_rows":50,"n_cols":21,"rows_kept":50,"cut":false,"hidden":false,"merged":[[19,8,20,8],[38,9,39,9],[41,9,42,9],[44,9,45,9],[22,8,23,8],[25,8,26,8],[31,8,32,8],[28,8,29,8],[9,10,9,11],[10,10,10,11],[11,10,11,11],[10,12,10,15],[9,14,9,15],[11,14,11,15],[0,1,0,6],[2,1,3,5],[2,6,3,6],[9,1,9,2],[9,5,9,6],[5,1,5,6],[6,1,6,6],[7,1,7,6],[10,1,10,2],[10,3,10,6],[11,1,11,2],[11,5,11,6],[13,1,13,6],[15,1,15,6],[18,1,20,2],[21,1,23,2],[24,1,26,2],[24,4,26,4],[24,5,26,5],[27,1,32,1],[48,1,48,6],[34,1,34,6],[37,1,39,2],[40,1,42,2],[43,1,45,2],[43,4,45,4],[27,2,29,2],[27,3,29,3],[27,4,29,4],[30,2,32,2],[30,3,32,3],[30,4,32,4],[49,1,59,6],[43,5,45,5],[46,1,46,2],[33,1,33,2],[33,3,33,5],[46,3,46,4]]}
[null,"利用料金確認書のご送付はＦＡＸが便利です。　ＦＡＸ ▶ ０３－５８３３－５６４１"]
[]
[null,"東プラ健診クリニック　　利用料金確認書 （以降、自動更新）",null,null,null,null,"支払方法"]
[]
[]
[null,"健診利用料金の支払方法について、必要事項をご記入の上、FAXまたは郵送にてご送付ください。"]
[null,"ピンク部分は入力必須項目となります。ピンク部分があると印刷できません。"]
[null,"※事業所控えとしてコピーをお取りいただき、お手元に保管ください。"]
[null,"※年度内変更不可",null,null,null,"記入日",null,null,null,null,"記入日",{"$f":"IF(G9=\"\",0,1)","v":0},null,null,null,null,null,{"$f":"L9","v":0}]
[null,"保険証記号",null,null,"事業所名",null,null,null,null,null,"保険証記号",null,{"$f":"IF(D10=\"\",0,1)","v":0},"事業所名",{"$f":"IF(F10=\"\",0,1)","v":0},null,null,{"$f":"IF(M10+O10=2,1,0)","v":0}]
[null,"事業所所在地",null,null,null,null,null,null,null,null,"事業所所在地",null,{"$f":"IF(D11=\"\",0,1)","v":0},null,null,null,null,{"$f":"M11","v":0}]
[null,"健診ご担当者名",null,null,"日中ご連絡のつく電話番号",null,null,null,null,null,"健診ご担当者名",null,{"$f":"IF(D12=\"\",0,1)","v":0},"日中ご連絡のつく電話番号",{"$f":"IF(F12=\"\",0,1)","v":0},null,null,{"$f":"IF(M12+O12=2,1,0)","v":0},null,null,{"$f":"SUM(R9:R12)","v":0}]
[]
[null,"\n　クリニック使用欄　（記入しないでください） "]
[]
[null,"＜記入方法について＞\n　◆ 健診コースごとに「受診予定あり」／「受診なし」を必ず☑してください。\n　　 受診の有無が未定の場合は「受診予定あり」を選択し、支払方法を選択してください。\n　◆ 被保険者、被扶養者ごとに健診コース・項目及び支払方法を☑してください。",null,null,null,null,null,null,null,null,true,false]
[null,null,null,null,null,null,null,null,null,"<入力判定>"]
[null,"１．被保険者"]
[null,null,null,"人間ドック","生活習慣病予防健診","定期健診",null,null,null,"人間ドック","生活","定期","確認用"]
[null,null,null,null,null,null,null,null,"受診",false,false,false]
[null,null,null,null,null,null,null,null,null,false,false,false]
[null,"基本料金",null,"10,000円","5,000円","6,472円",null,null,"判定",{"$f":"IF(OR(AND(J20=$L$16,J21=$L$16),AND(J20=$K$16,J21=$K$16)),0,IF(J20=$L$16,1,2))","v":0},{"$f":"IF(OR(AND(K20=$L$16,K21=$L$16),AND(K20=$K$16,K21=$K$16)),0,IF(K20=$L$16,1,2))","v":0},{"$f":"IF(OR(AND(L20=$L$16,L21=$L$16),AND(L20=$K$16,L21=$K$16)),0,IF(L20=$L$16,1,2))","v":0},{"$f":"IF(OR(J22=2,K22=2,L22=2),2,1)","v":1},"受診",2,"未受診",1,"エラー",0,{"$f":"COUNTIF(J22:L22,0)","v":3}]
[null,null,null,null,null,null,null,null,"支払",false,false,false]
[null,null,null,null,null,null,null,null,null,false,false,false]
[null,"胃カメラ検査\n（差額料金）",null,"6,600円","―","―",null,null,"判定",{"$f":"IF(J22=1,1,IF(OR(AND(J23=$L$16,J24=$L$16),AND(J23=$K$16,J24=$K$16)),0,3))","v":0},{"$f":"IF(K22=1,1,IF(OR(AND(K23=$L$16,K24=$L$16),AND(K23=$K$16,K24=$K$16)),0,3))","v":0},{"$f":"IF(L22=1,1,IF(OR(AND(L23=$L$16,L24=$L$16),AND(L23=$K$16,L24=$K$16)),0,3))","v":0},{"$f":"IF(OR(J25=0,K25=0,L25=0),0,2)","v":0},"選択済",3,null,null,null,null,{"$f":"COUNTIF(J25:L25,0)","v":3}]
[null,null,null,null,null,null,null,null,"カメラ",false]
[null,null,null,null,null,null,null,null,null,false]
[null,"定期健診向け\n  オプション","血液検査\n２","―","―","154円",null,null,"判定",{"$f":"IF(J22=1,1,IF(OR(AND(J26=$L$16,J27=$L$16),AND(J26=$K$16,J27=$K$16)),0,3))","v":0},1,1,{"$f":"IF(OR(J28=0,K28=0,L28=0),0,2)","v":0},null,null,null,null,null,null,{"$f":"COUNTIF(J28:L28,0)","v":1}]
[null,null,null,null,null,null,null,null,"血液２",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,"便潜血\n検査","―","―","990円",null,null,"判定",1,1,{"$f":"IF(L22=1,1,IF(OR(AND(L29=$L$16,L30=$L$16),AND(L29=$K$16,L30=$K$16)),0,3))","v":0},{"$f":"IF(OR(J31=0,K31=0,L31=0),0,2)","v":0},null,null,null,null,null,null,{"$f":"COUNTIF(J31:L31,0)","v":1}]
[null,null,null,null,null,null,null,null,"便潜血",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,false]
[null,"オプション検査",null,"原則、窓口支払となります。",null,null,null,null,"判定",1,1,{"$f":"IF(L22=1,1,IF(OR(AND(L32=$L$16,L33=$L$16),AND(L32=$K$16,L33=$K$16)),0,3))","v":0},{"$f":"IF(OR(J34=0,K34=0,L34=0),0,2)","v":0},null,null,null,null,null,null,{"$f":"COUNTIF(J34:L34,0)","v":1}]
[]
[null,null,null,null,null,null,null,null,null,null,true,false]
[null,null,null,"2．被扶養者　"]
[null,null,null,"人間ドック","生活習慣病予防健診※","※節目年齢の方は基本料金の\n   お支払いはございません。",null,null,null,null,"人間ドック","生活",null,"確認用"]
[null,null,null,null,null,null,null,null,null,"受診",false,false]
[null,null,null,null,null,null,null,null,null,null,false,false]
[null,"基本料金",null,"10,000円","5,000円",null,null,null,null,"判定",{"$f":"IF(OR(AND(K39=$L$36,K40=$L$36),AND(K39=$K$36,K40=$K$36)),0,IF(K39=$L$36,1,2))","v":0},{"$f":"IF(OR(AND(L39=$L$36,L40=$L$36),AND(L39=$K$36,L40=$K$36)),0,IF(L39=$L$36,1,2))","v":0},null,{"$f":"IF(OR(K4=2,L41=2),2,1)","v":1},null,null,null,null,null,null,{"$f":"COUNTIF(K41:M41,0)","v":2}]
[null,null,null,null,null,null,null,null,null,"支払",false,false]
[null,null,null,null,null,null,null,null,null,null,false,false]
[null,"胃カメラ検査\n（差額料金）",null,"6,600円","―",null,null,null,null,"判定",{"$f":"IF(K41=1,1,IF(OR(AND(K42=$L$36,K43=$L$36),AND(K42=$K$36,K43=$K$36)),0,3))","v":0},{"$f":"IF(L41=1,1,IF(OR(AND(L42=$L$36,L43=$L$36),AND(L42=$K$36,L43=$K$36)),0,3))","v":0},null,{"$f":"IF(OR(K44=0,L44=0),0,2)","v":0},null,null,null,null,null,null,{"$f":"COUNTIF(K44:M44,0)","v":2}]
[null,null,null,null,null,null,null,null,null,"カメラ",false]
[null,null,null,null,null,null,null,null,null,null,false]
[null,"オプション\n検査",null,"原則、窓口支払となります。",null,null,null,null,null,"判定",{"$f":"IF(K41=1,1,IF(OR(AND(K45=$L$36,K46=$L$36),AND(K45=$K$36,K46=$K$36)),0,3))","v":0},1,null,{"$f":"IF(OR(K47=0,L47=0),0,2)","v":0},null,null,null,null,null,null,{"$f":"COUNTIF(K47:M47,0)","v":1}]
[]
[null," その他支払方法、年齢対象外、年度内二度目、特殊健診等の受診予定がある場合はご記入ください。",null,null,null,null,null,null,null,{"$f":"IF(AND(J22=1,K22=1,L22=1,K41=1,L41=1),0,1)","v":1},null,{"$f":"IF(OR(M25=0,M28=0,M31=0,M34=0,N44=0,N47=0),0,2)","v":0},{"$f":"IF(SUM(R9:R12)=4,2,0)","v":0},{"$f":"IF(OR(COUNTIF(J22:L22,\"=0\")>0,COUNTIF(K41:L41,\"=0\")>0),0,2)","v":0}]
[null,null,null,null,null,null,null,null,null,"全て受診ナシ","受診あり入力漏れ","入力漏れ","基本情報","受診全記載"]