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["神戸市長あて",null,null,null,null,null,null,"請求年月日：令和７年　　　月　　　日"]
[]
[null,null,null,null,null,null,"住所"]
[null,null,null,null,null,null,"（法人名・）医療機関名"]
[null,null,null,null,null,null,"代表者氏名"]
[null,null,null,null,null,null,"電話番号"]
[]
["風しんの追加的対策　請求書（神戸市提出用）"]
[]
["以下の名義の預金口座に口座振替されるよう依頼します。"]
["（金融コード）",null,null,null,null,null,null,"（支店コード）"]
["金融機関名",null,null,null,null,null,null,"支店名"]
["預金種目",null,null,"普通　・　当座",null,null,null,"口座番号"]
["（フリガナ）"]
["口座名義人"]
[]
[null,null,null,null,null,null,null,"請求件数","請求金額\n（税抜）","請求金額\n（税込）"]
["抗体検査",null,null,"①健診：HI法、LTI法、ICA法"]
[null,null,null,"②健診：EIA法、ELFA法、CLEIA法、FIA法、CLIA法"]
[null,null,null,"③HI法、LTI法、ICA法"]
[null,null,null,"④EIA法、ELFA法、CLEIA法、FIA法、CLIA法"]
[null,null,null,"⑤夜間休日：HI法、LTI法、ICA法"]
[null,null,null,"⑥夜間休日：EIA法、ELFA法、CLEIA法、FIA法、CLIA法"]
[null,null,null,"小計"]
["予防接種",null,null,"MRワクチン"]
[null,null,null,"風しん単独ワクチン"]
[null,null,null,"予診のみ"]
[null,null,null,"小計"]
["合計"]
["※複数年度の請求が混在する場合、欄を修正してご使用いただくか、年度ごとに請求書を分けて\n　作成してください。"]
["※単価（MRワクチン）\n　2019.4～  ：9,270円（税抜）、10,011円（税込）\n　2019.10～：9,270円（税抜）、10,197円（税込）\n　2020.4～  ：9,330円（税抜）、10,263円（税込）\n　2022.4～  ：9,350円（税抜）、10,285円（税込）\n　2024.4～  ：9,410円（税抜）、10,351円（税込）"]
["※単価（風しん単独ワクチン）\n　2019.4～  ：6,000円（税抜）、6,480円（税込）\n　2019.10～：6,000円（税抜）、6,600円（税込）\n　2020.4～  ：6,060円（税抜）、6,666円（税込）\n　2022.4～  ：6,080円（税抜）、6,688円（税込）\n　2024.4～  ：6,140円（税抜）、6,754円（税込）"]