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["江西省门诊特殊慢性病病种待遇认定申请表"]
["□企业",null,null,"□机关事业单位",{"$nulls":3},"□其他（            ）"]
["姓名",null,"性别",null,"年龄",null,"□职工医保"]
[{"$nulls":6},"□城乡居民医保"]
["身份证号码",{"$nulls":3},"工作单位"]
["电话",{"$nulls":3},"申报病种名称"]
["选择定点医院","江西省胸科医院"]
["申请人承诺","本人保证所提供材料为本人看病就医资料，内容属实，真实合法有效，如有弄虚作假行为，本人愿承担由此产生的后果及应承担的法律责任。\n\n                                                             \n申请人签名： 年 月 日"]
["以下审批意见根据各地政策选填"]
["审批意见","定点医疗机构意见",{"$nulls":3},"医保经办机构意见"]
[null,"医师签名   \n\n\n医院医保管理部门（盖章）\n\n\n                   年  月  日\n",{"$nulls":3},"认定人签名  \n\n\n医保经办机构部门（盖章）\n\n\n                    年  月  日\n"]
[]
[]
[]
["备注"]
["注：1.每份表格仅限填报一种慢特病，附疾病证明书原件和申报病种相关的病历材料原件；"]