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["第２号様式（第４条第２項関係）"]
[]
["豊島区選択的介護協力事業者登録申請書"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,"豊島区長",null,null,null,null,null,null,null,null,null,null,null,null,"法人所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"申請者",null,null,"法人名称"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"代表者の職・氏名"]
[]
[]
["　豊島区選択的介護事業者登録制度実施要綱に係る協力事業者の登録を受けたいため、下記のとおり申請します。"]
["申請者","フリガナ"]
[null,"法人名称"]
[null,"法人所在地",null,null,null,null,null,"（　郵便番号　",null,null,null,"　",null,null,"－",null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,"都","道",null,null,null,null,"郡","市"]
[null,null,null,null,null,null,null,null,null,null,null,"府","県",null,null,null,null,"区"]
[null,"代表者の職・氏名",null,null,null,null,null,"職　名",null,null,null,null,null,null,null,null,null,null,"フリガナ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏　名"]
[null,"申請者の連絡先",null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ番号"]
["登録を受けようとする\n指定居宅介護支援事業所","フリガナ"]
[null,"事業所名称"]
[null,"事業所の\n所在地",null,null,null,null,null,"（郵便番号　",null,null,null,"　",null,null,"－",null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"東京都豊島区"]
[]
[null,"事業所連絡先",null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ番号"]
["事業所番号",null,null,null,null,null,null,1,3]
[]
["　【選択的介護協力事業者登録に係るチェックリスト】\n　選択的介護事業者登録制度の趣旨を理解したうえで、実施している項目のチェック欄に「✔」を記入してください。。"]
[]
[]
["チェック\n欄",null,"項目"]
[]
[null,null,"利用者の選択に資するよう、保険外サービスを含めたインフォーマルサービスについての情報収集および利用者への情報提供をおこなっている。"]
[]
[null,null,"自立支援の観点から、保険外サービスを含めたインフォーマルサービスを積極的にケアプランに位置付けている。"]
[]
["※選択的介護\n厚生労働省通知「介護保険サービスと保険外サービスを組み合せて提供する場合の取扱いについて」（平成30年９月28日老振発0928第１号）を前提として、介護サービス事業者が、利用者保護に配慮して、介護保険サービスと保険外サービスを適切に組み合わせて提供することを「選択的介護」といいます。　"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"担　当　者　連　絡　先"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先",null,null,"（電話）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（ＦＡＸ）"]