{"text_format":"3","workbook":"xls","n_sheets":19,"sheets":["封面","1-单位登记表","2-单位注销登记表  ","3-单位变更登记表","4-职工基本医疗保险参保登记表","5-基本医疗保险职工参保关系变更登记表","6-基本医疗保险职工参保信息变更登记表","7-城乡居民医疗保险参保登记表","8-基本医疗保险个人账户一次性支取申请表","表9-异地就医登记备案表","表10-门诊慢特病病种待遇认定申请表","表11-医疗救助申请表","表12-医疗机构申请定点协议管理申请表","表13-零售药店申请定点协议管理申请表","表14-定点医疗机构费用结算申报表","表15-就医人员明细表","表16-定点零售药店费用结算申报表","表17-购药人员明细表","表18-男职工未就业配偶承诺书"],"not_rendered":{"external_links":1,"defined_names":1},"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"封面","index":0,"n_rows":2,"n_cols":1,"rows_kept":2,"merged":[[0,0,0,8],[1,0,51,8]],"flags":["formulas_cached_only"]}
["附件3\n\n\n\n\n\n"]
["福建省医疗保障经办政务服务事项\n\n参考样表"]

{"sheet":"1-单位登记表","index":1,"n_rows":24,"n_cols":5,"rows_kept":24,"merged":[[0,0,0,5],[1,0,1,5],[2,0,2,5],[3,0,3,5],[4,0,4,5],[5,0,5,1],[5,2,5,3],[6,1,6,5],[7,0,8,0],[7,1,7,2],[7,3,7,5],[8,1,8,5],[9,0,10,0],[9,1,9,2],[9,3,9,5],[10,1,10,5],[11,1,11,5],[12,0,12,2],[12,3,12,5],[13,0,13,2],[13,3,13,5],[14,0,14,2],[14,3,14,5],[15,0,15,5],[16,0,17,0],[16,1,16,5],[17,1,17,3],[17,4,17,5],[18,0,18,2],[18,3,18,5],[19,1,19,5],[20,0,22,5]],"flags":["formulas_cached_only"]}
["表1：基本医疗保险单位参保信息登记表"]
["单位名称(公章）："]
["统一社会信用代码："]
["申请日期："]
["申请参保医疗经办机构：         医疗保障基金中心"]
["单位地址",{"$nulls":3},"邮　编"]
["单位      类型","□普通企业  □国有企业  □城镇集体企业  □外商投资企业   □机关  □财政核拨事业单位  □财政定额补助事业单位  □经费自给事业单位  □社会团体  □民办非企业单位  □其他        "]
["法定代表人或负责人","姓名：",null,"电话"]
[null,"身份证号码："]
["单位经办人员","姓名：",null,"电话"]
[null,"身份证号码："]
["参保险种","□医疗保险  □生育保险  □职工大额医疗费用补助   □其他（          ）"]
["人　员　分　类",null,null,"人　数"]
["在　职　职　工"]
["退　休  人　员"]
["机关事业单位、社会团体及国有企业填报以下信息"]
["批准成立信息","批准单位："]
[null,"批准日期：",null,null,"批准文号："]
["主管部门或总机构名称"]
["隶属     关系","□无   □中央属   □省属   □市属   □县（区）属   "]
["医疗保险经办\n机构审核意见（盖章）：          "]
[]
[]
["备注：适用于单位新参保登记"]

{"sheet":"2-单位注销登记表  ","index":2,"n_rows":20,"n_cols":6,"rows_kept":20,"merged":[[0,0,0,5],[1,0,1,5],[2,1,2,5],[3,0,14,0],[3,1,3,2],[3,3,3,4],[4,1,4,2],[4,3,4,4],[5,1,5,2],[5,3,5,4],[6,1,6,2],[6,3,6,4],[7,1,7,2],[7,3,7,4],[8,1,8,2],[8,3,8,4],[9,1,9,2],[9,3,9,4],[10,1,10,2],[10,3,10,4],[11,1,11,2],[11,3,11,4],[12,1,12,2],[12,3,12,4],[13,1,13,2],[13,3,13,4],[14,1,14,2],[14,3,14,4],[15,1,15,2],[15,3,15,4],[16,0,18,5]],"flags":["formulas_cached_only"]}
["表2：基本医疗保险单位注销登记表"]
["单位名称：（公章）                               申报日期："]
[" 医保单位编号："]
["注销原因",null,null,"对应项打“√”",null,"备  注"]
[null," 注销营业执照",null,"（            ）"]
[null," 吊销营业执照",null,"（            ）"]
[null," 破产（关闭）",null,"（            ）"]
[null," 兼（合）并",null,"（            ）"]
[null," 分    立",null,"（            ）"]
[null," 解    散",null,"（            ）"]
[null,"撤    销",null,"（            ）"]
[null," 批准或宣布终止",null,"（            ）"]
[null," 迁往本统筹外",null,"（            ）"]
[null," 其他原因",null,"（            ）"]
[null," 说        明"]
["单位经办人",null,null,"联系手机"]
["医疗保险经办\n机构审核意见（盖章）：          "]
[]
[]
["备注：适用于单位注销"]

{"sheet":"3-单位变更登记表","index":3,"n_rows":20,"n_cols":5,"rows_kept":20,"merged":[[0,0,0,4],[1,0,1,4],[2,0,2,1],[2,2,2,4],[3,0,3,1],[4,0,4,1],[5,0,5,1],[6,0,6,1],[7,0,9,0],[10,0,12,0],[13,0,13,1],[14,0,14,1],[15,0,15,1],[15,2,15,4],[16,0,18,4]],"flags":["formulas_cached_only"]}
["表3：基本医疗保险单位变更登记表"]
["单位名称：（公章）                                       填表日期："]
[" 医保单位编号："]
["变更事项",null,"对应项打“√”","变更前事项","变更后事项"]
["单位名称",null,"（        ）"]
["住所（地址）",null,"（        ）"]
["单位类型",null,"（        ）"]
["法定代表人            ","姓名","（        ）"]
[null,"证件号码","（        ）"]
[null,"联系电话","（        ）"]
["单位经办  人员            ","姓名","（        ）"]
[null,"证件号码","（        ）"]
[null,"联系电话","（        ）"]
["统一信用代码",null,"（        ）"]
["其他",null,"（        ）"]
["备注"]
["医疗保险经办\n机构审核意见（盖章）：          "]
[]
[]
["备注：适用于单位变更登记"]

{"sheet":"4-职工基本医疗保险参保登记表","index":4,"n_rows":30,"n_cols":15,"rows_kept":30,"merged":[[0,0,0,18],[2,0,2,18],[3,0,3,18],[5,1,5,8],[5,9,5,11],[5,12,5,18],[6,1,6,8],[6,9,6,11],[6,12,6,18],[7,1,7,8],[7,9,7,11],[7,12,7,18],[8,1,8,18],[9,1,9,8],[9,9,9,11],[9,12,9,18],[10,1,10,18],[11,0,13,0],[11,1,11,5],[11,6,11,8],[11,9,11,13],[11,14,11,18],[12,1,12,5],[12,6,12,8],[12,9,12,13],[12,14,12,18],[13,1,13,5],[13,6,13,8],[13,9,13,13],[13,14,13,18],[14,0,14,3],[14,4,14,8],[14,9,14,13],[14,14,14,18],[15,1,15,18],[16,0,16,3],[16,4,16,10],[16,11,16,18],[17,0,17,3],[17,4,17,10],[17,11,17,18],[18,0,18,3],[18,4,18,10],[18,11,18,18],[19,0,20,0],[19,1,19,3],[19,4,19,18],[20,1,20,3],[20,4,20,18],[21,0,27,18],[28,0,28,18],[29,0,29,18]],"flags":["formulas_cached_only"]}
["表4:职工基本医疗保险参保登记表"]
[]
[" 用人单位或代理单位全称：                                               "]
[" 医保单位编号：                                   申报日期：                     "]
["身份证号码"]
["姓    名",{"$nulls":8},"户口性质",null,null,"□城镇  □农村"]
["出生日期","           年     月     日",{"$nulls":7},"性    别",null,null,"□男     □女"]
["民    族",{"$nulls":8},"参加工作时间",null,null,"年      月"]
["通讯地址"]
["手机号码",{"$nulls":8},"邮政编码"]
["登记险种: ","□医疗保险  □生育保险  □职工大额医疗费用补助   □其他（          ）"]
["补缴申请","补缴险种",{"$nulls":4},"补缴工资基数",null,null,"补缴起始时间：",{"$nulls":4},"补缴截止时间："]
[null,"基本医疗保险",{"$nulls":7},"            年  月",{"$nulls":4},"         年  月"]
[null,"生育保险",{"$nulls":7},"            年  月",{"$nulls":4},"         年  月"]
["本次参保日期",{"$nulls":3}," 年   月",{"$nulls":4},"参保身份"]
["备注"]
[" 参保人员签章：               ",{"$nulls":3},"用人或代理单位：\n\n\n\n\n    \n            ",{"$nulls":6},"医保中心： "]
[" 签字（盖章）",{"$nulls":3}," 签字（盖章）",{"$nulls":6}," 签字（盖章）"]
[" 年   月  日 ",{"$nulls":3}," 年  月  日",{"$nulls":6}," 年  月  日"]
["参保人意见","□  中断超过3个月补缴",null,null,"本人自愿申请补缴____年____月至 ____年____月中断期间的职工基本医疗保险费，并执行下述等待期待遇政策。\n          "]
[null,"□  中断超过3个月不补缴",null,null,"本人不愿补缴中断缴费年限医保费，并从____年____月开始续保，并执行下述等待期待遇政策。"]
["职工基本医疗保险、生育保险参保登记注意事项：\n   1、职工基本医保中断缴费期间参加当地城乡居民医保等其他国家规定医疗保障方式的，再次申请参加职工基本医保时可以免于补缴中断缴费期间的医保费，参加当地城乡居民医保的年限不作为职工基本医保累计缴费年限。\n   2、职工医保新参保或转移接续参保人员，参保申请当月缴费的医疗保险关系当月生效，申请次月缴费的医疗保险关系次月生效，申请补缴当月之前保费的，原则上医疗保险关系仅从当月生效。\n   3、职工医保关系转移接续前中断缴费3个月（含）以内，申请补缴中断期间保费的，医疗保险关系生效时间可往前追溯至上一个基本医保关系生效开始时间。\n   4、职工医保关系中断3个月（不含）以上，补缴中断期间职工医保费的参保人员和新参保的参保人员，从职工基本医疗保险关系生效当月开始设置3个月待遇享受等待期，等待期内按连续参保人员职工医保待遇的50%享受。职工医保关系转移接续前中断缴费且不补缴中断期间职工医保费的参保人员，从职工基本医疗保险关系生效当月开始设置6个月待遇享受等待期，等待期内按连续参保人员职工医保待遇的50%享受。\n   5、单位职工医保参保人申请补缴当月（含当月）之前保费的，医保经办机构统一按上年度我省全口径城镇单位平均工资的60%为基数补缴职工医保、生育保险，医保经办机构经办的其他险种或补充保险原则上不补缴。补缴基数低于参保人在用人单位工资的，用人单位应自行申请差额补缴申报。\n   6、参保人员办理退休时，累计缴费年限(含视同缴费年限)满25年，在本统筹区实际缴费年限满10年。"]
[]
[]
[]
[]
[]
[]
["    本人已认真阅读上述事项，了解并愿意按相关政策申请参保。                  （内容由本人亲笔填写）"]
["             参保人（签字）：                  年     月     日    "]

{"sheet":"5-基本医疗保险职工参保关系变更登记表","index":5,"n_rows":15,"n_cols":10,"rows_kept":15,"merged":[[0,0,0,9],[3,0,4,0],[3,1,4,1],[3,2,4,2],[3,3,4,3],[3,4,3,8],[11,0,13,9]],"flags":["formulas_cached_only"]}
["表5:基本医疗保险职工参保关系变更登记表"]
["申报单位（盖章）：　　　                                            　　　　 医保单位编号：     　　　　　　　"]
["单位经办人：　                联系手机：                        ",{"$nulls":8},"申报时间："]
["序号","姓名","身份证号码","申报工资","变更类别",{"$nulls":4},"备　注"]
[{"$nulls":4},"减员","终止参保","在职转退休","退休暂停","其他"]
[1]
[2]
[3]
[4]
[5]
[6]
["医疗保险经办\n机构审核意见（盖章）：          "]
[]
[]
["备注：适用于人员减员、死亡、退休等关系变更业务"]

{"sheet":"6-基本医疗保险职工参保信息变更登记表","index":6,"n_rows":15,"n_cols":9,"rows_kept":15,"merged":[[0,0,0,8],[11,0,13,8]],"flags":["formulas_cached_only"]}
["表6:基本医疗保险参保信息变更登记表"]
["申报单位（盖章）：　　　                                            　　　　 医保单位编号：     　　　　　　　"]
["单位经办人：　                联系手机：                        ",{"$nulls":7},"申报时间："]
[" □关键信息变更（身份证号码、姓名等）",{"$nulls":3}," □非关键信息变更（手机号码、家庭住址等）"]
["序号","姓名","身份证号码","变更事项"," 变更前","变更后","变更年月","签字 ","备　注"]
[1]
[2]
[3]
[4]
[5]
[6]
["医疗保险经办\n机构审核意见（盖章）：          "]
[]
[]
["备注：适用于人员证件号码、手机号等参保信息变更"]

{"sheet":"7-城乡居民医疗保险参保登记表","index":7,"n_rows":23,"n_cols":12,"rows_kept":23,"merged":[[0,0,0,18],[1,0,1,18],[2,0,2,18],[4,1,4,5],[4,6,4,9],[4,10,4,18],[5,1,5,3],[5,4,5,5],[5,6,5,9],[5,10,5,13],[5,14,5,18],[6,0,7,0],[6,1,7,10],[6,11,7,13],[6,14,7,18],[8,1,8,18],[9,0,14,0],[9,1,9,18],[10,1,10,18],[11,1,11,18],[12,1,12,18],[13,1,13,18],[14,1,14,18],[15,0,17,0],[15,1,16,18],[17,1,17,18],[18,0,21,0],[18,1,21,18]],"flags":["formulas_cached_only"]}
["表7:城乡居民医疗保险参保登记表"]
["申请参保医疗经办机构：            医疗保障基金中心"]
["社区（村、居委会）：                                            顺序号： "]
["证件号码"]
["参保人姓名",{"$nulls":5},"证件名称",{"$nulls":3},"□身份证□户口簿□居住证□港澳台通行证"]
["性   别","□男  □女",null,null,"出生年月",null,"年     月",{"$nulls":3},"手机号码"]
["户籍所在地（居住证登记地）","    市        区县(市)      街道(乡镇)",{"$nulls":9},"社区（村、居委会）"]
[]
["通讯地址"]
["申请人身份","□1周岁以内新生儿"]
[null,"□未就业的城乡居民"]
[null,"□未就业的港澳台居民"]
[null,"□在校学生"]
[null,"□宗教教职人员及工作人员"]
[null,"□其他             "]
["申请人\n或监护人","    以上信息填报真实，现申请参加城乡居民医保，并已了解城乡居民基本医疗保险费征收部门和缴费方式，以及每年规定的缴费时间。"]
[]
[null,"（签字）                              年      月    日"]
["收件审核","经审核，符合城乡居民医保参保规定。\n经办人:                       （受理单位盖章）\n复核人:                        年      月     日\n (受理单位指社区（村、居委会）或劳动站、医保中心按对象分别审核)"]
[]
[]
[]
["备注：适用于城乡居民新参保登记"]

{"sheet":"8-基本医疗保险个人账户一次性支取申请表","index":8,"n_rows":21,"n_cols":3,"rows_kept":21,"merged":[[0,0,0,3],[2,0,2,3],[4,1,4,3],[5,1,5,3],[6,1,6,3],[7,1,7,3],[8,0,8,3],[12,1,12,3],[13,1,13,3],[14,0,14,3],[15,0,15,1],[15,2,15,3],[16,0,19,0],[16,1,17,3],[18,1,18,3],[19,1,19,3]],"flags":["formulas_cached_only"]}
["表8:基本医疗保险个人账户一次性支取申请表\n"]
[]
["参保人基本情况"]
["姓名",null,"身份证件号码"]
["支取原因","口死亡     口出国（境）定居      口其他      "]
["工作单位"]
["转入银行开户行"]
["银行账户号码"]
["领取人（继承人、代表人）基本情况"]
["姓名",null,"与参保人关系"]
["证件类型及号码",null,"联系电话"]
["常住地址",null,"工作单位"]
["转入银行开户行"]
["银行账户号码"]
["    经协商，由          代表全部继承人办理支取业务，有关款项汇入其名下医保卡个人账户或银行账户，分配事宜自行解决，由此产生的法律纠纷由代表人自行负责。\n                                         \n                           "]
["\n申请人签字（加盖手印）\n\n联系电话\n\n申请时间：      年     月     日\n",null,"单位意见\n\n\n                        签字（盖章）\n                      年      月       日"]
["医疗保险经办机构审核"]
[]
[null,"    经办人：                  复核：                 "]
[null,"                                          年    月    日"]
["备注：适用于参保人员死亡、出国等一次性支取"]

{"sheet":"表9-异地就医登记备案表","index":9,"n_rows":19,"n_cols":6,"rows_kept":19,"merged":[[0,0,0,5],[2,0,6,0],[2,1,2,3],[2,4,6,4],[2,5,6,5],[3,1,3,3],[4,1,4,3],[5,1,5,3],[6,1,6,3],[7,1,7,5],[8,1,8,3],[9,1,9,3],[10,1,10,2],[10,4,10,5],[11,0,11,5],[12,0,12,5],[13,0,13,5],[14,0,14,5],[15,0,15,5],[16,0,16,5],[17,1,17,3]],"flags":["formulas_cached_only"]}
["表9：异地就医登记备案表"]
["姓名",null,"性别",null,"险种","□职工医保             □城乡居民医保"]
["人员类别","□异地安置退休人员",null,null,"登记类别","□新增          □变更"]
[null,"□异地长期居住人员"]
[null,"□常驻异地工作人员"]
[null,"□异地转诊人员"]
[null,"□其他临时外出就医人员"]
["身份证号码"]
["参保地联系地址",{"$nulls":3},"就医地联系地址"]
["联系电话1",{"$nulls":3},"联系电话2"]
["转往省（市、区）",null,null,"地区（市、州）"]
["温馨提示"]
["  1.跨省异地就医直接结算执行就医地规定的支付范围及有关规定，参保地规定的基本医疗保险基金起付标准、支付比例、最高支付限额、门诊慢特病病种范围等有关政策。"]
["  2.办理备案时直接备案到就医地市或直辖市。参保人员根据病情、居住地、交通等情况，自主选择就医地开通的跨省联网定点医疗机构住院就医。门诊就医时按照参保地异地就医管理要求选择跨省联网定点医药机构就诊。"]
["  3.到海南、西藏等省级统筹的省份和新疆生产建设兵团就医的，可备案到就医省份和新疆生产建设兵团。"]
["  4.异地急诊抢救人员视同已备案。"]
["  5.未按规定办理登记备案手续，或在就医地非跨省定点医疗机构发生的医疗费用，按参保地现有规定执行。"]
["□本人   □被委托人     签名",{"$nulls":3},"填表日期"]
["经办机构：",null,"联系电话：",null,"经办人：","  经办日期："]

{"sheet":"表10-门诊慢特病病种待遇认定申请表","index":10,"n_rows":10,"n_cols":7,"rows_kept":10,"merged":[[0,0,0,6],[1,0,1,1],[1,2,1,4],[1,5,1,6],[3,1,3,3],[3,5,3,6],[4,1,4,3],[4,5,4,6],[5,1,5,6],[6,0,7,0],[6,1,6,6],[7,1,7,5],[8,1,8,6],[9,1,9,6]],"flags":["formulas_cached_only"]}
["表10：门诊慢特病病种待遇认定申请表"]
["认定机构名称（盖章）：",{"$nulls":4},"年    月   日"]
["姓名",null,"性别",null,"年龄",null,"□职工医保        □城乡居民医保"]
["身份证件号码",{"$nulls":3},"联系电话"]
["选择定点医院",{"$nulls":3},"申请人签名"]
["申报病种名称","                                             (此栏请按照标准病种名称填写)"]
["申报病种情况（符合诊断标准项目）","                                                 医师签名：                                                                                                                                                                                             "]
[{"$nulls":6},"年    月    日"]
["审批意见"]
["备注"]

{"sheet":"表11-医疗救助申请表","index":11,"n_rows":29,"n_cols":13,"rows_kept":29,"merged":[[0,0,0,13],[1,0,2,0],[1,1,1,2],[1,3,1,4],[1,6,1,7],[1,8,1,10],[1,11,1,13],[2,1,2,2],[2,3,2,8],[2,9,2,11],[2,12,2,13],[3,0,7,0],[3,1,3,13],[4,1,4,13],[5,1,5,13],[6,1,6,13],[7,1,7,13],[8,1,8,13],[9,0,9,13],[10,0,11,1],[10,2,10,3],[10,4,11,6],[10,7,11,9],[10,10,11,11],[10,13,11,13],[11,2,11,3],[12,0,13,1],[12,2,12,3],[12,4,13,6],[12,7,13,9],[12,10,13,11],[12,13,13,13],[13,2,13,3],[14,0,17,0],[14,1,14,13],[15,1,15,13],[16,1,16,13],[17,1,17,13],[18,0,21,0],[18,1,18,13],[19,1,19,13],[20,1,20,13],[21,1,21,13],[22,1,22,13],[23,1,23,13],[24,1,24,13],[25,1,25,13],[26,1,26,13],[27,0,28,0],[27,1,27,13],[28,1,28,13]],"flags":["formulas_cached_only"]}
["表11：医疗救助申请表"]
["申请人基本情况","姓名",{"$nulls":3},"性别",null,null,"身份\n证件号码"]
[null,"家庭住址",{"$nulls":7},"联系电话"]
["申请\n救助对象\n类别","□第一类：特困供养人员、孤儿（含事实无人抚养儿童）；"]
[null,"□第二类：重点优抚对象、革命“五老”人员、计划生育特殊家庭成员、重度残疾人；"]
[null,"□第三类：最低生活保障对象、农村易返贫致贫人员、脱贫（享受政策）人员；"]
[null,"□第四类：最低生活保障边缘家庭成员；"]
[null,"□第五类：因病致贫家庭重病患者。"]
["银行账户及开户行"]
["申请医疗费用信息（如我省系统已有基本医疗、大病保险数据，可直接提取核对使用）"]
["住院费用",null,"结算",{"$nulls":4},"住院总费用（元）",{"$nulls":4},"医保结算"]
[null,null,"次数",{"$nulls":9},"清单张数"]
["门诊费用",null,"结算",{"$nulls":4},"门诊总费用（元）",{"$nulls":4},"医保结算"]
[null,null,"次数",{"$nulls":9},"清单张数"]
["申请人（代办人）承诺","本人保证符合此业务办理条件，所述信息真实，由此产生的一切法律责任均由本人承担。"]
[]
[null,"　　　　　　申请人（代办人）签名：    "]
[null,"　　　　　　　　　　　　申请日期：   　　 　　     年   月   日"]
["相关部门认定意见"]
[]
[null,"　　　　　　　　　　　　　认定部门（盖章）："]
[null,"　　　　　　　　　　　　　　　　　　　　　　　　　　年　　月　　日"]
["经办机构","　　经审核，本次予以医疗救助　　　　　　　元。"]
["意见"]
[]
[null,"　　科室审核：　　　　　　　　　复核：　　　　　　　　初审："]
[null,"　　　　　　　　　　　　　　　　　　　　　　　　　　　　　年　　月　　日"]
["备注","1.此表用于第一至四类人员医疗待遇未实现“一站式”结算及第五类人员申请医疗救助；"]
[null,"2.第五类人员此表需认定部门确认盖章。如认定部门有提供盖章的确认名单或报告，可用名单或报告替代。"]

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["表13"]
[" "]
[" "]
[" "]
["定点医疗机构申请表"]
["(参考样表)"]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
["申请单位：__________________"]
["申请时间：     年    月    日"]
["填写说明"]
[" "]
["一、本表采用打印版，要求内容真实。"]
["二、“申请业务内容”一栏是指开展“门诊”“住院”。"]
["三、“医保职能部门”一栏是指医疗机构内部设立或指定的负责医疗保障业务管理的部门。"]
[" "]
[]
["定点医疗机构申请表"]
[" "]
["医疗机构名称",null,null,"医疗机构地址"]
["统一社会信用代码",null,null,"所有制形式"]
["执业许可证号",null,null,"主管部门"]
["经营性质",null,null,"正式运营时间"]
["批准床位数",null,null,"经营面积"]
["基本账户开户",null,null,"医疗机构等级"]
["银行及账号"]
["法定代表人","姓名：",null,"联系电话："]
[null,"身份证号码："]
["实际控制人","姓名：",null,"联系电话："]
["(主要负责人)","身份证号码："]
["主管医保工作",null,null,"联系电话"]
["负责人"]
["医保职能部门",null,null,"联系电话"]
["联系人"]
["在职职工人数",null,null,"在本单位缴纳社保、"]
[{"$nulls":3},"医保人数"]
["申请业务内容","住院□              门诊□"]
["卫技人员汇总",null,"人数",null,"第一注册地在本机构的人数"]
["情况(以注册","医生"]
["人员为准)","护士"]
[null,"医技"]
[null,"药师"]
[null,"合计"]
["科室设置、医护人员(以注册人员为准)、病床数情况","科室","住院开放",null,"医生人数",null,null,"护士人数","其他"]
[null,null,"床位数",null,"(其中第一注册地在"]
[{"$nulls":4},"本医疗机构的人数)"]
[]
[]
[]
["大型医疗设备信息","品种",null,null,"型号及数量",null,null,"购买年月","有效期"]
[]
[]
[]
[]
[]
[]
["申请承诺"]
[]
[]
[]
[]
[]
[null,"本机构自愿申请承担医疗保障服务，并严格遵守医疗保障有关管理规定，对所提交资料的真实性负责，如有虚假不实，本机构将承担由此带来的一切法律、经济等方面的后果及责任。"]
[null,"本机构已认真阅读《医疗机构医疗保障定点管理暂行办法》（国家医疗保障局令第2号）申请定点相关要求，无第十二条不予受理情形；已认真阅读xxx医疗保障定点医疗机构协议管理要求，承诺在申请纳入协议管理后严格遵守协议管理的各项要求。"]
[]
[]
[]
[]
[]
[]
[null,"法定代表人签字：                   （单位盖章）"]
[]
[null,"                                                 年   月   日"]
["联系人",{"$nulls":3},"联系电话"]
["风险提示：申请定点的医疗机构有可能存在前期经费投入，当评估不合格时可能会产生经济损失。"]

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["表13"]
[" "]
[" "]
[" "]
["定点零售药店申请表"]
["(参考样表)"]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
["申请单位： __________________"]
["申请时间：     年    月    日"]
["填写说明"]
[" "]
["一、本表采用打印版，要求内容真实。"]
["二、劳动合同有效时限填写劳动合同签订日期及合同期限。"]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[" "]
[]
["定点零售药店申请表"]
[" "]
["药店名称",{"$nulls":5},"药店地址"]
["统一社会信用代码",{"$nulls":5},"药品经营许可证号"]
["所有制形式",{"$nulls":5},"药店性质",null,null,"直营□加盟□"]
[{"$nulls":9},"单体□其他□"]
["药店许可经营范围"]
["营业面积",{"$nulls":5},"基本账户"]
["（平方米）",{"$nulls":5},"开户银行及账号"]
["上级公司名称",{"$nulls":5},"上级公司地址"]
["法定代表人",null,"姓名：",{"$nulls":3},"联系电话："]
[null,null,"身份证号码："]
["是否独立法人",null,"是□          否□"]
["企业负责人",null,"姓名：",{"$nulls":3},"联系电话："]
[null,null,"身份证号码："]
["实际控制人",null,"姓名：",{"$nulls":3},"联系电话："]
[null,null,"身份证号码："]
["药师配置情况",null,"姓名","性别",null,"年龄","技术资格","发证日期",null,"证书编号","注册地","劳动合同"]
[{"$nulls":11},"有效时限"]
[]
[]
["医保管理",{"$nulls":5},"联系电话"]
["工作负责人"]
["医保管理",{"$nulls":5},"医保管理工作兼职人数"]
["工作专职人数"]
["医保管理人员",null,"姓名","身份证号码",null,null,"专(兼)职","劳动合同有效时限"]
[]
[]
["申"]
[]
["请"]
[]
["承"]
[]
["诺"]
[]
[]
[]
[]
[null,"本单位自愿申请承担医疗保障服务，并严格遵守医疗保障有关管理规定，对所提交资料的真实性负责，如有虚假不实，本机构将承担由此带来的一切法律、经济等方面的后果及责任。"]
[null,"本机构已认真阅读《零售药店医疗保障定点管理暂行办法》（国家医疗保障局令第3号）申请定点相关要求，无第十一条不予受理情形；已认真阅读xxx医疗保障定点零售药店协议管理要求，承诺在申请纳入协议管理后严格遵守协议管理的各项要求。"]
{"$rows_empty":14}
[null,"法定代表人签字：                  (单位公章)"]
[]
[null,"  年   月   日"]
["联系人",{"$nulls":3},"联系电话"]
["风险提示：申请定点的零售药店有可能存在前期经费投入，当评估不合格时可能会产生经济损失。"]
[" "]

{"sheet":"表14-定点医疗机构费用结算申报表","index":14,"n_rows":15,"n_cols":9,"rows_kept":15,"merged":[[0,0,0,8],[1,1,1,4],[1,6,1,8],[2,1,2,3],[2,4,2,5],[2,6,2,8],[3,1,3,3],[3,4,3,5],[3,6,3,8],[4,0,6,0],[4,1,5,2],[4,3,6,4],[4,5,6,5],[4,6,6,6],[4,7,6,7],[4,8,6,8],[7,3,7,4],[8,3,8,4],[9,3,9,4],[10,3,10,4],[11,3,11,4],[12,0,12,8],[13,0,13,8]],"flags":["formulas_cached_only"]}
["表14：定点医疗机构费用结算申报表\n（月度汇总数据）"]
["申请日期：    年    月    日",{"$nulls":5},"  单位：元,人次"]
["定点医疗机构代码",{"$nulls":3},"定点医疗机构名称（盖章）"]
["申报起止日期","年   月   日至     年   月   日",null,null,"定点医疗机构归属统筹区"]
["就医地类别","申报合计",null,"医疗总费用",null,"基金支付合计","账户支付合计","现金支付合计","备注"]
[]
[null,"人次","金额"]
[]
[]
[]
[]
["合     计"]
["                         结算申请人：                                                      医保办负责人：                  "]
["经办机构意见：\n\n\n                                                                                       经办人：        年   月   日"]
["备注：本表限定点医疗机构在经办窗口办理费用结算使用"]

{"sheet":"表15-就医人员明细表","index":15,"n_rows":17,"n_cols":17,"rows_kept":17,"merged":[[0,0,0,16],[1,0,1,1]],"flags":["formulas_cached_only"]}
["表15：就医人员明细表"]
["机构代码：",{"$nulls":3},"机构名称（盖章）：",null,null,"申报起止时间：   年  月  日至  年  月  日",{"$nulls":6},"申报日期：  年  月  日"]
["序号","定点机构代码","定点医疗机构名称","定点归属医保区划","就诊人姓名","就诊人证件号码","险种类型","参保所属区划","就诊凭证","退费标志","结算ID","结算时间","医疗类别","医疗费总额","现金支付金额","基金支付总额","账户支付总额"]
{"$rows_empty":13}
["备注：1.本表限定点医疗机构在经办窗口办理费用结算使用；2.单位：元"]

{"sheet":"表16-定点零售药店费用结算申报表","index":16,"n_rows":15,"n_cols":9,"rows_kept":15,"merged":[[0,0,0,8],[1,1,1,4],[1,6,1,8],[2,1,2,3],[2,4,2,5],[2,6,2,8],[3,1,3,3],[3,4,3,5],[3,6,3,8],[4,0,6,0],[4,1,5,2],[4,3,6,4],[4,5,6,5],[4,6,6,6],[4,7,6,7],[4,8,6,8],[7,3,7,4],[8,3,8,4],[9,3,9,4],[10,3,10,4],[11,3,11,4],[12,0,12,8],[13,0,13,8]],"flags":["formulas_cached_only"]}
["表16：定点零售药店费用结算申报表\n（月度汇总数据）"]
["申请日期：    年    月    日",{"$nulls":5},"  单位：元，人次"]
["定点零售药店代码",{"$nulls":3},"定点零售药店名称（盖章）"]
["申报起止日期","年   月   日至     年   月   日",null,null,"定点零售药店归属统筹区"]
["就医地类别","申报合计",null,"医疗总费用",null,"基金支付合计","账户支付合计","现金支付合计","备注"]
[]
[null,"人次","金额"]
[]
[]
[]
[]
["合     计"]
["                         结算申请人：                                                     业务负责人：                  "]
["经办机构意见：\n\n\n                                                                                       经办人：        年   月   日"]
["备注：本表限定点零售药店在经办窗口办理费用结算使用"]

{"sheet":"表17-购药人员明细表","index":17,"n_rows":17,"n_cols":17,"rows_kept":17,"merged":[[0,0,0,16],[1,0,1,1]],"flags":["formulas_cached_only"]}
["表17：购药人员明细表"]
["机构代码：",{"$nulls":3},"机构名称（盖章）：",null,null,"申报起止时间：   年  月  日至  年  月  日",{"$nulls":6},"申报日期：  年  月  日"]
["序号","定点零售药店代码","定点零售药店名称","定点归属医保区划","购药人姓名","购药人证件号码","险种类型","参保所属区划","购药凭证","退费标志","结算ID","结算时间","医疗类别","医疗费总额","现金支付金额","基金支付总额","账户支付总额"]
{"$rows_empty":13}
["备注：1.本表限定点零售药店在经办窗口办理费用结算使用；2.单位：元"]

{"sheet":"表18-男职工未就业配偶承诺书","index":18,"n_rows":13,"n_cols":1,"rows_kept":13,"flags":["formulas_cached_only"]}
["表18：男职工未就业配偶承诺书"]
[]
["            医保中心："]
["本人姓名：            ，身份证号：               __  ；"]
["配偶姓名：           ，身份证号：                   ，于     年"]
["月  日分娩，未享受生育保险待遇。配偶生育当年未就业未参加新型农村合作医疗或城镇居民基本医疗保险，现申请按规定结算此次分娩住院医疗费用待遇。"]
["本人承诺以上及所提交材料真实有效，愿意承担因此造成的一切法律后果。"]
["  "]
[" "]
[" "]
["承诺人（签名、手印）：           "]
["                                        年    月    日"]
[" "]