XLS《表一申请鉴定表》

"表一: "咸阳市城镇医疗保险(渭城)门诊特殊病申请鉴定表" "单位(社区)盖章:填表时间:年月日" "姓名",,

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,"性别",,

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"年龄",,

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"照片粘贴处",,

, "电话",,

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,"手机" "家庭住址" "单位(社区) "申请门诊特殊病病种" "身份证号" "病情摘要:鉴定结果:专家签名: "鉴定医院(盖章)医疗保险经办机构(盖章) "备注",,

"此表一式一份,前六行由本人填写,单位名称填全称且盖章;

申请病种仅限一种;

身份证号填写二代身份证号.

鉴定结束后由鉴定医院将此表(仅限鉴定通过人员)统一交所属市、县区医保中心. "表二: "城镇职工(居民)申请门诊特殊病人员统计表" "单位(社区)名称:(盖章)人员类别(职工/居民):填报时间:年月日" "序号","姓名","身份证号","申请门诊特殊病名称","单位名称",,

"单位经办人","手机","电话" "1" "2" "3" "4" "5" "注:申请门诊特殊病名称统一按门诊特殊病病种汇总所列病种名称填写(表格可向下追加),单位名称填全称且盖章. ,,

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"城镇职工(居民)申请门诊特殊病病种汇总" "序号","病种名称",,

"申请人数","序号","病种名称","申请人数",,

"1","原发性高血压2级以上(含2级)",,

,"10","系统性红斑狼疮",,

, "2","冠状动脉粥样硬化性心脏病",,

,"11","帕金森综合症",,

, "3","脑血管病恢复期",,

,"12","恶性肿瘤晚期",,

, "4","慢性肾小球肾炎及肾病综合症",,

,"13","多耐药肺结核",,

, "5","慢性再生障碍性贫血",,

,"14","慢性活动性肝炎",,

, "6","糖尿病及糖尿病伴并发症",,

,"15","类风湿性关节炎",,

, "7","肝硬化失代偿期",,

,"16","甲状腺功能亢进",,

, "8","慢性肺源性心脏病",,

,"17","甲状腺功能减退",,

, "9","精神疾病",,

,"合计",,

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, "表三: "城镇职工(居民)异地安置人员申请门诊特殊病人员统计表" "单位(社区)名称:(盖章)人员类别(职工/居民):填报时间:年月日" "序号","姓名","身份证号","申请门诊特殊病名称","单位(社区)名称",,

"单位经办人","手机","电话" "1" "2" "3" "4" "5" "注:申请门诊特殊病名称统一按门诊特殊病病种汇总所列病种名称填写(表格可向下追加),单位名称填全称且盖章. ,,

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"城镇职工(居民)异地安置人员申请门诊特殊病病种汇总" "序号","病种名称",,

"申请人数","序号","病种名称","申请人数",,

"1","冠状动脉粥样硬化性心脏病",,

,"5","系统性红斑狼疮",,

, "2","慢性再生障碍性贫血",,

,"6","恶性肿瘤晚期",,

, "3","肝硬化失代偿期",,

,"7","类风湿性关节炎",,

, "4","精神疾病",,

,"合计",,

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"表四: "门诊特殊病(异地安置人员)医疗费用报销统计表" "单位名称:年月日单位:元" "姓名","病种名称","身份证号","上年7月―今年6月门诊特殊病医疗费用"费用合计" ,,

,"7月","8月","9月","10月","11月","12月","1月","2月","3月","4月","5月","6月", ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" ,,

"审核情况" "备注:医疗费用及费用合计保留至小数点后两位数值" "单位经办人:联系