[별지 제8호 서식] 장기요양등급변경신청서

[별지 제8호서식] <개정 2008.6.11> (앞쪽) <TABLE style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; BORDER-BOTTOM: #000000 0.28pt solid; BORDER-COLLAPSE: collapse"> <TBODY> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 1.7pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 43.55pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 40.95pt" vAlign=center colSpan=2> ① 신청 구분</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 1.7pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 405.42pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 40.95pt" vAlign=center colSpan=9> □ 장기요양등급 변경신청서 □ 장기요양 급여종류ㆍ내용 변경신청서</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 43.55pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 107.31pt" vAlign=center colSpan=2 rowSpan=4> 신청인 (본인)</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ② 성명</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 100.54pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> </TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 90.2pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=3> ③ 주민등록번호</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 138.28pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=4> -</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ④ 주민등록지</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 329.02pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=8> </TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 28.95pt" vAlign=center> ⑤ 실제거주지</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 329.02pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 28.95pt" vAlign=center colSpan=8> </TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ⑥ 전화번호</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 190.74pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=4> (휴대전화)</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 44.94pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=3> E-mail</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 93.34pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ＠</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 43.55pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center colSpan=2> 보호자</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center> ⑦ 성명</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 100.54pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center> </TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 55.59pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center colSpan=2> ⑧ 신청인과의 관계</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 34.61pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center> </TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 44.94pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center colSpan=3> ⑨ 전화번호</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 93.34pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 32.46pt" vAlign=center> </TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 43.55pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 124.94pt" vAlign=center colSpan=2 rowSpan=5> 대리인</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ⑩ 성명</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 100.54pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> </TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 90.2pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=3> ⑪ 주민등록번호</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 138.28pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=4> -</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 46.58pt" vAlign=center rowSpan=2> ⑫ 유형</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 329.02pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 23.29pt" vAlign=center colSpan=8> 1. 가족ㆍ친족ㆍ이해관계인(신청인과의 관계: ) </TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 142.27pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 23.29pt" vAlign=center colSpan=2> 2.사회복지전담공무원</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 186.75pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 23.29pt" vAlign=center colSpan=6> 3.시장ㆍ군수ㆍ구청장이 지정한 자</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ⑬ 주소</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 329.02pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=8> </TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 76.4pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> ⑭ 전화번호</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 193.57pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=5> (휴대전화)</TD> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 39.28pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center> E-mail</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 96.17pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.12pt" vAlign=center colSpan=2> @</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 119.95pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.16pt" vAlign=center colSpan=3> ⑮ 변경신청 사유</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 329.02pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 26.16pt" vAlign=center colSpan=8> </TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 448.97pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 148.4pt" vAlign=center colSpan=11> 「노인장기요양보험법」 제21조, 제22조 및 같은 법 시행규칙 제9조에 따라 위와 같이 장기요양등급(장기요양급여종류ㆍ내용)의 변경을 신청합니다. . . . 신청인: (서명 또는 인) 대리인: (서명 또는 인) 국민건강보험공단 이사장 귀하</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 35.06pt; BORDER-BOTTOM: #000000 1.7pt solid; HEIGHT: 128.59pt" vAlign=center> 구비서류</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 413.91pt; BORDER-BOTTOM: #000000 1.7pt solid; HEIGHT: 128.59pt" vAlign=center colSpan=10> 1. 별지 제2호서식의 의사소견서(등급변경신청시에만 제출하고, 추후에 제출할 수 있으며, 「노인장기요양보험법 시행령」 제6조에 해당하는 경우에는 제출하지 아니합니다) 2. 대리인 관련서류 가. 가족, 친족 또는 이해관계인: 대리인의 신분증 나. 사회복지전담공무원: 공무원임을 증명하는 신분증 다. 시장ㆍ군수ㆍ구청장이 지정한 자: 별지 제9호서식의 대리인 지정서 3. 변경신청 사유가 장기요양급여 종류를 가족요양비로 변경하는 경우: 별지 제17호서식의 가족요양비 지급 신청서와 관련 구비서류</TD></TR></TBODY></TABLE>[(210㎜ × 297㎜[일반용지60g/㎡(재활용품)] (뒤쪽) <TABLE style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 0.28pt solid; BORDER-BOTTOM: #000000 0.28pt solid; BORDER-COLLAPSE: collapse"> <TBODY> <TR> <TD style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; WIDTH: 451.55pt; BORDER-BOTTOM: #000000 1.7pt solid; HEIGHT: 27.95pt" vAlign=center colSpan=2> 이 신청서는 다음과 같이 처리됩니다. (처리기간은 30일 정도 소요됩니다)</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 0.28pt solid; BORDER-TOP: #000000 1.7pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 121.39pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 25.12pt" vAlign=center> 신청인</TD> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 1.7pt solid; BORDER-LEFT: #000000 0.28pt solid; WIDTH: 330.16pt; BORDER-BOTTOM: #000000 0.28pt solid; HEIGHT: 25.12pt" vAlign=center> 접수 및 처리(국민건강보험공단)</TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 0.28pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 451.55pt; BORDER-BOTTOM: #000000 1.7pt solid; HEIGHT: 106.13pt" vAlign=center colSpan=2> <?xml:namespace prefix = v ns = "urn:schemas-microsoft-com:vml" /><v:shapetype id=_x0000_t75 filled="f" stroked="f" path="m@4@5l@4@11@9@11@9@5xe" o:preferrelative="t" o:spt="75" coordsize="21600,21600"><v:stroke joinstyle="miter"></v:stroke><v:formulas><v:f eqn="if lineDrawn pixelLineWidth 0"></v:f><v:f eqn="sum @0 1 0"></v:f><v:f eqn="sum 0 0 @1"></v:f><v:f eqn="prod @2 1 2"></v:f><v:f eqn="prod @3 21600 pixelWidth"></v:f><v:f eqn="prod @3 21600 pixelHeight"></v:f><v:f eqn="sum @0 0 1"></v:f><v:f eqn="prod @6 1 2"></v:f><v:f eqn="prod @7 21600 pixelWidth"></v:f><v:f eqn="sum @8 21600 0"></v:f><v:f eqn="prod @7 21600 pixelHeight"></v:f><v:f eqn="sum @10 21600 0"></v:f></v:formulas><v:path o:connecttype="rect" gradientshapeok="t" o:extrusionok="f"></v:path><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:lock aspectratio="t" v:ext="edit"></o:lock></v:shapetype><v:shape id=_x66514584 style="MARGIN-TOP: 0.13pt; MARGIN-LEFT: 5.24pt; WIDTH: 431.48pt; POSITION: absolute; HEIGHT: 75.76pt; v-text-anchor: top; mso-position-vertical-relative: line; mso-position-vertical: absolute; mso-position-horizontal-relative: text; mso-position-horizontal: absolute" type="#_x0000_t75"><v:imagedata src="file:///C:\DOCUME~1\박연선\LOCALS~1\Temp\DRW000008d40b00.gif" o:title="DRW000008d40b00"></v:imagedata></v:shape></TD></TR> <TR> <TD style="BORDER-RIGHT: medium none; BORDER-TOP: #000000 1.7pt solid; BORDER-LEFT: medium none; WIDTH: 451.55pt; BORDER-BOTTOM: #000000 1.7pt solid; HEIGHT: 25.12pt" vAlign=center colSpan=2> <작성요령 및 유의사항></TD></TR> <TR> <TD style="BORDER-RIGHT: #000000 1.7pt solid; BORDER-TOP: #000000 1.7pt solid; BORDER-LEFT: #000000 1.7pt solid; WIDTH: 451.55pt; BORDER-BOTTOM: #000000 1.7pt solid; HEIGHT: 459.36pt" vAlign=center colSpan=2> ①: 장기요양등급 변경신청 또는 장기요양 급여종류ㆍ내용 변경신청 중 해당하는 곳에 √표 합니다. - 장기요양등급 변경신청: 장기요양인정을 받은 자의 심신상태가 호전되거나 악화되어 등급을 변경하려는 경우 - 장기요양 급여종류ㆍ내용 변경신청: 장기요양급여의 종류ㆍ내용을 변경하려는 경우 ②～⑥: 신청인의 성명, 주민등록번호, 주민등록지, 실제거주지(주민등록주소와 다른 경우), 전화번호, E-mail을 적습니다. ※ 실거주지는 방문조사 및 등급판정 결과 등 각종 우편물 수령지이므로 추후 실제거주지 변경이 있는 경우 공단에 신고하셔야 합니다. ⑦～⑨: 보호자의 성명, 신청인과의 관계, 전화번호를 적습니다. ⑩～⑪: 대리인의 성명, 주민등록번호를 적습니다. ※ 해당하는 경우에만 기재합니다. ⑫: 대리인의 유형을 1 ~ 3번 중 해당되는 곳에 O표 합니다. 1. 가족, 친족, 이해관계인: 신청인과의 관계를 적습니다. - 가족: 「민법」 제779조에 따른 가족으로서 배우자, 직계혈족, 형제자매, 직계혈족의 배우자, 배우자의 직계혈족 및 배우자의 형제자매 - 친족: 「민법」 제777조에 따른 친족으로서 8촌 이내 혈족, 4촌 이내 인척, 배우자 - 이해관계인: 가족, 친족을 제외한 이웃 등 그 밖의 자 2. 사회복지전담공무원: 「사회복지사업법」에 따른 사회복지전담공무원 3. 시장ㆍ군수ㆍ구청장이 지정한 자: 가족, 친족, 이해관계인 또는 사회복지전담공무원이 장기요양인정신청 등을 할 수 없는 경우 시장ㆍ군수ㆍ구청장이 지정하는 자 ⑬～⑭: 대리인의 주소, 전화번호, E-mail을 적습니다. ⑮: 장기요양등급 또는 급여종류ㆍ내용의 변경을 신청한 사유를 간략하게 적습니다.</TD></TR></TBODY></TABLE>   <a href="javascript:checkVirus('grpid%3DsApl%26fldid%3DApwg%26dataid%3D36%26fileid%3D1%26regdt%3D20111219210311')"><img src="https://t1.daumcdn.net/daumtop_deco/icon/icon.hanmail.net/editor/p_hwp_s.gif" border="0" alt="첨부파일" class="vam"/> [별지 제8호서식] 장기요양등급 변경신청서.hwp</a>