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["附件2："]
["河北省省直参保职工\n享受省直37种慢性病待遇申请表"]
["姓名",null,null,"性别",null,"年龄",null,"单位"]
["单位编码",null,null,"社会保障号"]
["简明病史及治疗情况："]
{"$rows_empty":7}
["诊断："]
[]
[]
[]
[]
[]
["科室名称:",null,null,"副主任（及其以上）医师签字："]
["申请认定病种"]
["医院医保办意见：",null,null,"单位人事部门意见：",{"$nulls":3},"专家组审核意见："]
[]
[]
[]
[]
["         公  章",{"$nulls":4},"公  章",null,null,"    公    章"]
["     年   月   日",{"$nulls":3},"  年   月   日",{"$nulls":3}," 年   月   日"]
["备\n\n\n注","1、此表仅限享受省直公务员医疗补助及10%补充保险待遇的参保职工使用。\n2、必须提交的资料：申报本次慢性病时，省医保中心统一组织的慢性病体检报告、原发病史资料及近期病史资料（要求半年以上）、相关检查、化验单、心电图、MRI片、X光片、CT片及报告单等。（各相关检查化验单要必须有相关科室或检验医师手章或是医院的印章）\n3、本表中填写的具体用药和治疗项目不作为今后报销的依据。"]

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