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["江西省医疗保险双通道药品使用终止表"]
["姓名",null,"性别",null,"相片"]
["医保卡号",null,"年龄"]
["身份证号",null,"联系电话"]
["人员类别","□职工医保□城乡居民医保"]
["参保属地",null,"工作单位"]
["双通道医疗机构",null,"双通道零售药店"]
["疾病诊断",null,"确诊时间","年     月    日"]
["使用药品名称",null,"使用终止时间","年     月    日"]
["双通道医疗机构意见"]
[]
[null,"经评估，该患者无需继续使用双通道药品：                  。"]
{"$rows_empty":10}
[null,"责任医师签章：              双通道医疗机构医保管理部门盖章： "]
[]
[null,"年    月    日"]
["    注：本表由双通道医疗机构责任医生填写后报所在双通道医疗机构医保管理部门，由双通道医疗机构医保管理部门及时并向参保地医疗保障部门备案。"]