導(dǎo)語：城鎮(zhèn)職工醫(yī)療保險(xiǎn)市外就醫(yī)申請書一文來源于網(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)申請書"

,,,,,,"(住院/特門)"

"參保人",,"性別",,"年齡",,"身份證號"

"參保單位:",,,,,,"社保號"

"申請就醫(yī)的醫(yī)院名稱:"

"住院時(shí)間:年月日至年月日",,,,,,"聯(lián)系電話"

"申請理由:"

,,,"申請人:",,,"年月日"

"審批意見:"

,,,,"審批人:",,"年月日"

"核對身份意見:"

"核對人:","年月",,,"日核對人:",,"年月日"

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

"第二頁"

"注意事項(xiàng):"

"一,辦理申請時(shí),請附疾病診斷證明書,門診急診病歷復(fù)印件.沒有辦理長期居住異地"

"手續(xù)的,請?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?jiān)诔鲈?天內(nèi)持身份證辦理核對身份及報(bào)銷手續(xù).自出院日起計(jì)超過90天不辦理"

"報(bào)銷手續(xù)的視為自動放棄,不予辦理報(bào)銷手續(xù)."

"三,按醫(yī)院級別支付標(biāo)準(zhǔn):"

"醫(yī)院級別",,"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"

"一級醫(yī)院",,"在職",400,,"98%","90%"

,,"退休",300,,"100%"

"二級醫(yī)院",,"在職",600,,"90%"

,,"退休",500,,"93%"

"三級醫(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"

"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."