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[]
[null,"指定（介護予防）福祉用具貸与事業所事前提出書類"]
[]
[]
[null,"〇　事業所名"]
[]
[]
[null,"〇　サービスの提供状況"]
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[null,"介護予防貸与","利用者数計"]
[null,null,"車いす"]
[null,null,"車いす付属品"]
[null,null,"特殊寝台"]
[null,null,"特殊寝台付属品"]
[null,null,"床ずれ防止用具"]
[null,null,"体位変換器"]
[null,null,"手すり"]
[null,null,"スロープ"]
[null,null,"歩行器"]
[null,null,"歩行補助つえ"]
[null,null,"認知症老人徘徊感知機器"]
[null,null,"移動用リフト"]
[null,null,"自動排泄処理装置"]
[null,"福祉用具貸与","利用者数計"]
[null,null,"車いす"]
[null,null,null,"例外使用"]
[null,null,"車いす付属品"]
[null,null,null,"例外使用"]
[null,null,"特殊寝台"]
[null,null,null,"例外使用"]
[null,null,"特殊寝台付属品"]
[null,null,null,"例外使用"]
[null,null,"床ずれ防止用具"]
[null,null,null,"例外使用"]
[null,null,"体位変換器"]
[null,null,null,"例外使用"]
[null,null,"手すり"]
[null,null,"スロープ"]
[null,null,"歩行器"]
[null,null,"歩行補助杖"]
[null,null,"認知症老人徘徊感知機器"]
[null,null,null,"例外使用"]
[null,null,"移動用リフト"]
[null,null,null,"例外使用"]
[null,null,"自動排泄処理装置"]
[null,null,"（注１）　利用者数は、介護報酬請求に係る実利用者数を記入してください。（直近12か月分）"]
[null,null,"（注２）　緑で着色してある箇所には、軽度者で原則算定できないが、例外使用として算定した場合の実利用者数を内数で記入してください。"]
[]
[null,null,"　"]

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[]
[null,"指定特定（介護予防）福祉用具販売事業所事前提出書類"]
[]
[]
[null,"〇　事業所名"]
[]
[]
[null,"〇　サービスの提供状況"]
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[null,null,null,null,null,null,null,null,"月",{"$f":"IF(H10=\"\",\"\",IF(H10=12,1,H10+1))","v":""},"月",{"$f":"IF(J10=\"\",\"\",IF(J10=12,1,J10+1))","v":""},"月",{"$f":"IF(L10=\"\",\"\",IF(L10=12,1,L10+1))","v":""},"月",{"$f":"IF(N10=\"\",\"\",IF(N10=12,1,N10+1))","v":""},"月",{"$f":"IF(P10=\"\",\"\",IF(P10=12,1,P10+1))","v":""},"月",{"$f":"IF(R10=\"\",\"\",IF(R10=12,1,R10+1))","v":""},"月",{"$f":"IF(T10=\"\",\"\",IF(T10=12,1,T10+1))","v":""},"月",{"$f":"IF(V10=\"\",\"\",IF(V10=12,1,V10+1))","v":""},"月",{"$f":"IF(X10=\"\",\"\",IF(X10=12,1,X10+1))","v":""},"月",{"$f":"IF(Z10=\"\",\"\",IF(Z10=12,1,Z10+1))","v":""},"月",{"$f":"IF(AB10=\"\",\"\",IF(AB10=12,1,AB10+1))","v":""},"月"]
[null,"介護予防販売","利用者数計"]
[]
[null,null,"腰掛便座"]
[]
[null,null,"自動排泄処理装置の交換可能部品"]
[]
[null,null,"入浴補助用具"]
[]
[null,null,"簡易浴槽"]
[]
[null,null,"移動用リフトの吊り具"]
[]
[null,null,"排泄予測支援機器"]
[]
[null,"特定用具販売","利用者数計"]
[]
[null,null,"腰掛便座"]
[]
[null,null,"自動排泄処理装置の交換可能部品"]
[]
[null,null,"入浴補助用具"]
[]
[null,null,"簡易浴槽"]
[]
[null,null,"移動用リフトの吊り具"]
[]
[null,null,"排泄予測支援機器"]
[]
[null,null,"（注）　利用者数は、介護報酬請求に係る実利用者数を記入してください。（直近12か月分）"]