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[" 基本医疗保险费用报销申请表  （空表）                 "]
[{"$nulls":6},"医疗费用年度："]
["姓  名",null,"医疗保险号（身份证号）",{"$nulls":3},"联系电话"]
["报销原因","退休异地安置□   退休异地长期居住□   异地工作□   转外就医□   自行转外□   急诊□   外伤□   其它(   )"]
["本人银行账号",null,null,"开户行及网点名称"]
["申请报销分类","普通门诊","发票张数",null,"发票总金额"]
[null,"门慢特病种1","发票张数",null,"发票总金额",null,"门慢特病种名称1："]
[null,"门慢特病种2","发票张数",null,"发票总金额",null,"门慢特病种名称2:"]
[null,"门慢特病种3","发票张数",null,"发票总金额",null,"门慢特病种名称3:"]
[null,"住    院","发票张数",null,"发票总金额"]
[null,"体    检","发票张数",null,"发票总金额"]
["申请人或代办人签名：",{"$nulls":5},"申请时间："]
["填表须知：","1、不同医疗年度应单独填写此表，例如同时有2019年度费用、2020年度费用应分两张申请表填写。医疗费用年度以医疗费用发生日期为准。"]
[null,"2、不同报销类别以及不同类型的门慢特病种（俗称特殊病种）都应分开，以免待遇受影响。"]
[null,"3、如您还需在其它部门（工会、商业保险等）办理报销手续，请在提交材料之前复印留存。"]