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[]
[null,"指定（介護予防）訪問リハビリテーション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"]
[null,"提供年"]
[null,"提供月"]
[null,"利用者数（要介護）"]
[null,"利用者数（要支援）"]
[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）"]
[]
[null,"特別地域訪問リハビリテーション加算",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　該当　・　　非該当"]
[]
[null,"中山間地域等における小規模事業所加算（地域に関する状況）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　該当　・　　非該当"]
[]
[null,"中山間地域等における小規模事業所加算（規模に関する状況）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　該当　・　　非該当"]
[]
[null,"中山間地域等に居住する者へのサービス提供加算",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"短期集中リハビリテーション実施加算",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"リハビリテーションマネジメント加算",null,null,null,null,null,null,null,"有［　　イ　・　　ロ　　］・　　無"]
[]
[null,"サービス提供体制強化加算",null,null,null,null,null,null,null,"有［　　Ⅰ　・　　Ⅱ　・　　Ⅲ　］・　　無"]
[]
[null,"移行支援加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"口腔連携強化加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"退院時共同指導加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"認知症短期集中リハビリテーション加算",null,null,null,null,null,null,null,"　有　・　　無"]