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[null,"保険適用希望書　【A２区分】　の入力が終わりましたら、下記のボタンを押下し、入力項目に不備がないかチェックをお願いします。"]
[null,"チェック結果がNGの場合は、対象の入力項目の値を再度ご確認ください。"]
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[null,null,null,null,"チェック結果"]
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[null,null,"No","シート名","セル名","項目名",null,"メッセージ"]

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["希望書",null,null,null,null,"様式1-1",null,null,"様式2-1",null,null,"早見表",null,null,"反映ボタン"]
["項目名","項目値","入力チェック",null,null,"項目名","項目値","入力チェック","項目名","項目値","入力チェック","データ\n開始行番号","項目名","列番号","反映元","反映先"]
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["決定区分","A2","　","　","　","使用目的又は効果","-","○","希望区分の名称","F3","○",null,"機能区分名",9]
["希望する特定保険医療材料の区分","G3","○",null,null,"形状、構造及び原理","-","○","定義","A9","○"]
["保険適用希望種別","G5","○","　","　","原材料","-","○","承認書又は認証書該当ページ／内容","G9","○"]
["算定する関連診療報酬項目","G8","○","　","　","使用方法","-","○","補足説明","P9"]
["販売名","G9","○","　","　","医療ニーズの高い医療機器への指定の有無","-","○","希望区分における類似製品の名称","F16"]
["製品名","G12","○","　","　",null,null,null,"当該製品の概要","A18"]
["製品コード","M12","○","　","　"]
["製品コード数","R12","○","　","○"]
["類別","G13","○","　"]
["一般的名称","R13","○","　","　"]
["承認番号、認証番号又は届出番号","G15","○","○","　"]
["承認年月日、認証年月日又は届出年月日","R15","○"]
["最終一部変更年月日","R17",null,"　","　"]
["製品概要","G18","○","　","　"]
["医療機関向け取扱い説明書","M21","○","　","　"]
["パンフレット","M23","○","　","　"]
["メンテナンスの要・不要","H26","○","　","　"]
["使用成績を踏まえた再評価希望の有無","H29","○","　","　"]
["希望小売価格（参考）","G31","○","　","　"]
["担当者名","J32","○","　","　"]
["電話番号","Q32","○","　","　"]
["E-mail","Q33","○","　","　"]
["備考","G34","○","　","　"]
["提出年","C40","○","　","　"]
["提出月","E40","○","　","　"]
["提出日","G40","○","　","　"]
["住所（上段）","B42","○","　","　"]
["住所（下段）","B43",null,"　","　"]
["氏名（会社名）","B45","○","　","　"]
["氏名（代表者）","B46",null,"　","　"]

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["別紙2",null,null,null,null,null,null,null,"   医療機器保険適用希望書",null,null,null,null,null,null,"整理番号"]
["（決定区分Ａ２（特定包括））"]
["希望する特定診療報酬算定\n医療機器の区分"]
[]
["保険適用希望種別",null,null,null,null,null,"1","．新規"]
[null,null,null,null,null,null,"2","．販売名、製品名、製品コードの追加・変更"]
[null,null,null,null,null,null,"3","．使用目的又は効果の追加・変更"]
["算定する関連診療報酬項目"]
["販売名"]
[]
["製品名・製品コード",null,null,null,null,null,"製品名",null,null,null,null,null,"製品コード",null,null,null,null,"製品コード数"]
[]
["類別",null,null,null,null,null,null,null,null,null,null,null,"一般的名称"]
[]
["承認番号\n認証番号又は\n届出番号",null,null,null,null,null,null,null,null,null,null,null,"承認年月日、 \n認証年月日又は\n届出年月日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"（及び最終一部変更年月日）"]
["製品概要"]
[]
["医療機関向け取扱い説明書\n又は\nパンフレットの有無"]
[null,null,null,null,null,null,"医療機関向け取扱い説明書",null,null,null,null,null,"　",null,"有",null,"・",null,"無"]
[]
[null,null,null,null,null,null,"パンフレット",null,null,null,null,null,null,null,"有",null,"・",null,"無"]
[]
["メンテナンスの要・不要"]
[null,null,null,null,null,null,"　",null,null,null,"要",null,"・",null,"不要"]
[]
["使用成績を踏まえた\n再評価希望の有無"]
[null,null,null,null,null,null,"　",null,null,null,"有"," （","収載時",null,"・","収載後",null,"）","・",null,"無"]
[]
["希望小売価格（参考）"]
["担当者連絡先",null,null,null,null,null,"担当者名：",null,null,null,null,null,null,"電話番号："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"E-mail："]
["備考"]
[]
[]
[]
[]
["上記により、医療機器の保険適用を希望いたします。"]
[null,"令和",null,"年",null,"月",null,"日"]
["住所（法人にあっては、主たる事務所の所在地）"," 住所（法人にあっては、主たる事務所の所在地）"]
[]
[]
["氏名（法人にあっては、名称及び代表者の氏名）"," 氏名（法人にあっては、名称及び代表者の氏名）"]
[]
[]
[]
["厚生労働大臣",null,null,null,null,null,null,null,"殿"]

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["様式1-1"]
["医療機器保険適用希望資料"]
["使用目的又は効果"]
[]
[]
[]
[]
[]
[]
[]
["形状、構造及び原理"]
[]
[]
[]
[]
[]
[]
["原材料"]
[]
[]
[]
[]
[]
["使用方法"]
[]
[]
[]
[]
[]
["医療ニーズの高い医療機器への指定の有無"]
[null,null,null,null,null,null,"　",null,null,null,"有",null,null,"・",null,null,"無"]

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["様式2-1"]
["希望区分及び区分選定の根拠"]
["希望区分の名称",null,null,null,null,{"$f":"IF(希望書!$G$3=\"\",\"\",希望書!$G$3)","v":""}]
[]
[]
["選定した根拠"]
["＜",null,null,null,null,null,null,null,null," ＞"]
["定義",null,null,null,null,null,"承認書又は認証書該当ページ／内容",null,null,null,null,null,null,null,null,"補足説明"]
[]
[]
[]
[]
[]
[]
["以上により、選定した特定診療報酬算定医療機器の区分「",null,null,null,null,null,null,null,null,null,null,{"$f":"IF(B7=\"\",\"\",B7)","v":""},null,null,null,null,null,null,null,"」に該当する。"]
["希望区分における類似製品の名称"]
["当該製品の概要"]

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["別添資料1"]
[null,null,"製品名・製品コードリスト"]
[]
[]
[null,"製品名","製品コード","製品仕様・規格","承認書該当ページ","備考"]
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["保険適用通知フォーマット"]
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["保険適用通知フォーマット"]
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[{"$f":"IF(希望書!$G$6=\"②\",希望書!$G$15,\"\")","v":""},{"$f":"IF(希望書!$G$6=\"②\",希望書!$G$9,\"\")","v":""},null,null,{"$f":"IF(希望書!$G$6=\"②\",希望書!$B$45,\"\")","v":""},{"$f":"IF(希望書!$G$6=\"②\",希望書!$G$3,\"\")","v":""}]

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["別表1",null,null,"別表2"]
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