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["武汉市社会保险医疗费用申报表"]
["学校名称（盖章）：",{"$nulls":17},"  险  种：大学生医保□"]
["参    保    人    信    息",null,"姓  名",{"$nulls":3}," ",{"$nulls":6},"联系电话"]
[null,null,"身份证号"]
["代    办    人    信    息",null,"姓    名"]
[null,null,"联系电话"]
["急救 申请",null,"  就诊类别",{"$nulls":3},"1、市内急救",{"$nulls":6},"2、市外急救",{"$nulls":9},"备注: 填报要求见填报说明第三条"]
[{"$nulls":6},"3、市内无卡",{"$nulls":6},"4、常驻外地、易地安置人员报销"]
["就诊医院"]
["住院时间"]
["医   疗   费   用  申   报",null,"住院总费用",{"$nulls":17},"是否死亡"]
[null,null,"报销费用划拨方式",null,1,"  交通银行卡",{"$nulls":17},"备注：      参保人需提供本人银行卡号及开户行名称"]
[{"$nulls":4},2,"  学校代发"]
[{"$nulls":4},3,"  划其他银行卡"]
[null,null,"附   报   资   料  名  称",{"$nulls":16},"各 险 种 申 报 要 求"]
[{"$nulls":19},"职保","居保","工伤","生育","离休","伤残"]
[null,null,1,"费用资料原件：①发票②住院费用汇总清单               \n 住院病历资料复印件：③出院小结④病案首页⑤临时医嘱⑥长期医嘱⑦手术记录和麻醉记录（手术患者附报）⑧门(急)诊病历及检查报告单、病理检查报告⑨身份证复印件               \n",{"$nulls":15},"√","√","√","√","√","√"]
[null,null,2," 转院审批表",{"$nulls":15},"√","√","√","√","√","√"]
[null,null,3,"参保人交通银行卡和身份证复印件",{"$nulls":16},"√"]
[null,null,4," 外地医院等级证明（参保人可在网上查询打印）",{"$nulls":15},"√","√","√","√","√","√"]
[null,null,5," 生育保险就医登记表",{"$nulls":18},"√"]
[null,null,6," 大学生医保：实习、休学者附学校证明",{"$nulls":16},"√"]
[null,null,7," 其他：“报销费用划拨方式”说明：（1）“交通银行卡”，参保人可持交通银行卡到银行柜台取款；（2）“单位代发”报销款打到学校账户，由学校代发给学生本人，学校持《结算单》或单位收据到医保中心结算窗口办理倒进帐手续；（3）“其他银行卡”，参保人可提供参保人其他银行卡，报销费用划拨相应银行。（学生需提供武汉市内的银行卡号和开户行名称等相关银行卡信息）"]
[]
[null,null,"受理人：",{"$nulls":8},"审核人：",{"$nulls":8},"复核人："]
["温馨提示：请参保人在上交报销材料时，自留发票、清单及出院小结、长期医嘱、临时医嘱、手术记录、麻醉记录、各项检查报告单复印件备用。"]