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[]
[null,"指定（予防）通所リハビリテーション事業所事前提出書類"]
[]
[]
[null,null,"通常規模型　　　大規模型（Ⅰ）　　　大規模型（Ⅱ）"]
[]
[null,"〇　事業所名"]
[]
[]
[null,"〇　単位数",null,null,null,null,null,null,null,"単位"]
[]
[]
[null,"〇　利用者数"]
[null,"利用定員",null,null,null,null,null,null,null,null,null,null,null,"　人（運営規程に定められている定員）"]
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[null,"現　員",null,null,null,null,null,null,null,null,null,null,null,"　人（前年度4月～２月までの1日当たりの平均）"]
[]
[]
[]
[]
[null,"〇サービスの提供状況"]
[null,"理学療法士等体制強化加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"リハビリテーション提供体制加算",null,null,null,null,null,null,null,"　有　・　　無"]
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[null,"短期集中個別リハビリテーション実施加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"生活行為向上リハビリテーション実施加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"若年性認知症利用者受入加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"栄養アセスメント加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"栄養改善加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"重度療養管理加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"中重度者ケア体制加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"科学的介護推進体制加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"移行支援加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"退院時共同指導加算",null,null,null,null,null,null,null,"　有　・　　無"]
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[null,"一体的サービス提供加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,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,"　有　・　　無"]
[]
[null,"入浴介助加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　］・　　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　・　　ハ　］・　　無"]
[]
[null,"認知症短期集中リハビリテーション実施加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　］・　　無"]
[]
[null,"口腔・栄養スクリーニング加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　］・　　無"]
[]
[null,"口腔機能向上加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　］・　　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"]