導(dǎo)語(yǔ)：城鎮(zhèn)職工醫(yī)療保險(xiǎn)市外就醫(yī)申請(qǐng)書(shū)一文來(lái)源于網(wǎng)友上傳，不代表本站觀點(diǎn)，若需要原創(chuàng)文章可咨詢(xún)客服老師，歡迎參考。

"順德區(qū)城鎮(zhèn)職工醫(yī)療保險(xiǎn)市外就醫(yī)申請(qǐng)書(shū)"

,,,,,,"(住院/特門(mén))"

"參保人",,"性別",,"年齡",,"身份證號(hào)"

"參保單位:",,,,,,"社保號(hào)"

"申請(qǐng)就醫(yī)的醫(yī)院名稱(chēng):"

"住院時(shí)間:年月日至年月日",,,,,,"聯(lián)系電話(huà)"

"申請(qǐng)理由:"

,,,"申請(qǐng)人:",,,"年月日"

"審批意見(jiàn):"

,,,,"審批人:",,"年月日"

"核對(duì)身份意見(jiàn):"

"核對(duì)人:","年月",,,"日核對(duì)人:",,"年月日"

"辦事處或駐院辦公室:",,,,"經(jīng)辦簽名:",,,"收表日期:"

"第二頁(yè)"

"注意事項(xiàng):"

"一,辦理申請(qǐng)時(shí),請(qǐng)附疾病診斷證明書(shū),門(mén)診急診病歷復(fù)印件.沒(méi)有辦理長(zhǎng)期居住異地"

"手續(xù)的,請(qǐng)?zhí)峁┡R時(shí)居住地及與居住地親人關(guān)系的證明材料."

"二,請(qǐng)?jiān)诔鲈?天內(nèi)持身份證辦理核對(duì)身份及報(bào)銷(xiāo)手續(xù).自出院日起計(jì)超過(guò)90天不辦理"

"報(bào)銷(xiāo)手續(xù)的視為自動(dòng)放棄,不予辦理報(bào)銷(xiāo)手續(xù)."

"三,按醫(yī)院級(jí)別支付標(biāo)準(zhǔn):"

"醫(yī)院級(jí)別",,"人員身份","起付標(biāo)準(zhǔn)(元)",,"統(tǒng)籌基金支付比例","補(bǔ)充基金支付比例"

"一級(jí)醫(yī)院",,"在職",400,,"98%","90%"

,,"退休",300,,"100%"

"二級(jí)醫(yī)院",,"在職",600,,"90%"

,,"退休",500,,"93%"

"三級(jí)醫(yī)院",,"在職",1200,,"85%(惡性腫瘤,心腦疾病手術(shù)治療,肝,腎,骨髓移植按90%)"

,,"退休",1000

"四,凡轉(zhuǎn)到市外醫(yī)院的按以下比例支付:"

"1,經(jīng)市內(nèi)定點(diǎn)醫(yī)療機(jī)構(gòu)轉(zhuǎn)診并經(jīng)社保局核準(zhǔn),到市外指定醫(yī)療機(jī)構(gòu)住院的,納入基本"

"醫(yī)療保險(xiǎn)的費(fèi)用按市內(nèi)同等級(jí)定點(diǎn)醫(yī)療機(jī)構(gòu)的支付比例支付;"

"2,因病情需要,經(jīng)社保局核準(zhǔn)后直接到市外指定醫(yī)療機(jī)構(gòu)住院的,納入基本醫(yī)療保險(xiǎn)"

"的費(fèi)用按市內(nèi)同級(jí)定點(diǎn)醫(yī)療機(jī)構(gòu)支付比例的90%支付;"

"3,經(jīng)社保局核準(zhǔn)到市外非指定醫(yī)療機(jī)構(gòu)住院的,納入基本醫(yī)療保險(xiǎn)的費(fèi)用按市內(nèi)同級(jí)"

"定點(diǎn)醫(yī)療機(jī)構(gòu)支付比例的60%支付;"

"4,未經(jīng)社保局核準(zhǔn)自行到非指定醫(yī)療機(jī)構(gòu)住院的醫(yī)療費(fèi)統(tǒng)籌基金不予支付."