【Form C】 (様式Ｃ) Request to Attending Physician or Superintendent of Hospital／Clinic (担当医または病院事務長へのお願い) 1. Please fill in this form so that the patient may claim the social insurance benefit. (この様式は、患者の社会保険の給付申請に必要ですので、証明をお願いします。) 2. This form should be completed and signed by either the attending physician or the ｓuperintendent of (この様式は、担当医または病院の事務長が記入し、かつ署名して下さい。) the hospital / clinic . 3. One form for each month and one form for hospitalization / outpatient should be filled out. (各月毎、入院・外来毎に、この様式１枚が必要です。) 4. If not in dollars, please specify the unit used. (ドル以外の通貨の場合は、その旨を書いて下さい。) Itemized Ｒ Receipt Permanent Teeth（永久歯）８７６５４３２１ | １２３４５６７８８７６５４３２１ | １２３４５６７８ Dental Treatment (歯科治療) 1. 2. 3. 4. 5. 6. 7. (初診料) (Ｘ線検査) (抜髄) (抜歯) (充填) (インレー) (Dental) Ｌ Localization of Teeth Examined (患歯部位) Initial Office Visit X-ray Examination Dental Pulp Extirpation Extraction Filling Inlay Amal. / Comp. Build-up (領収明細書・歯科) Deciduous Teeth（乳歯）ｅｄｃｂａ | ａｂｃｄｅｅｄｃｂａ | ａｂｃｄｅＲ Material (材料) Date (日付) MO DA YR ＄ 8. Post c Core (メタルコア) (金属冠) 9. Metal Crown / resin (継続歯) 10. Post Crown (ｼﾞｬｹｯﾄ冠) 11. Jacket Crown (ﾌﾞﾘｯｼﾞ) 12. Bridge Work 13. Plate Denture (有床義歯) Partial Denture (局部義歯) Complete Denture (総義歯) 14. Periodontal Scaling/Root planing ＄＄＄＄＄＄＄ (歯肉下歯石除去・根面平滑化) (盲嚢掻爬) 15. Gingival Curettage (投薬) 16. Medicine 17. The others Details of treatment, Localization of Teeth Examined, Material ＄＄＄ (処置内容、患歯部位、材料) (合計) Total (貨幣単位) Unit is ＄ Name and Address of Attending Physician/Superintendent of Hospital or Clinic (担当医又は病院事務長の名前および住所) Name (名前) Name of Hospital or Clinic （病院または診療所名称） Address (住所) Signature (署名) Fee (治療費) ＄＄＄＄＄＄ (アマルガム・複合レジンによる支台築造) Date (日付) Ｌ (MO)／ (DA)／ (YR) 領収明細書・歯科（様式Ｃ）の日本語訳 Dental Treatment Material (材料) (歯科治療) 1. Initial Office Visit (初診料) 2. X-ray Examination (Ｘ線検査) 3. Dental Pulp Extirpation (抜髄) 4. Extraction (抜歯) 5. Filling (充填) 6. Inlay (インレー) 7. Amal. / Comp. Build-up (アマルガム・複合レジンによる支台築造) 8. Post c Core (メタルコア) 9. Metal Crown / resin (金属冠) 10. Post Crown (継続歯) 11. Jacket Crown (ｼﾞｬｹｯﾄ冠) 12. Bridge Work (ﾌﾞﾘｯｼﾞ) 13. Plate Denture Partial Denture Complete Denture (有床義歯) (局部義歯) (総義歯) 14. Periodontal Scaling/Root planing (歯肉下歯石除去・根面平滑化) 15. Gingival Curettage (盲嚢掻爬) 16. Medicine (投薬) 17. The others Details of treatment, Localization of Teeth Examined, Material (処置内容、患歯部位、材料) 翻訳者の記入欄（被保険者・被扶養者でも可）日付氏名 (自署) 住所電話平成年月日印