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["武汉市医疗生育保险报销申报表"]
["参保单位名称：",null,"险种：职保□  居保□  生育□  离休□  伤残□"]
["参保人信息","姓名",null,null,"身份证号",{"$nulls":3},"参保人联系电话"]
[null,"配偶姓名(生育报销填写)",null,null,"配偶身份证号",{"$nulls":3},"配偶联系电话"]
["代办人信息","姓名",null,null,"身份证号",{"$nulls":3},"联系电话"]
["生育信息","生育类别","□顺产□助娩产□剖宫产 □流、引产□计生手术",null,"计生手术类别","□放置(取出)宫内节育器 □(取出)皮下埋植术□输卵管复通术 □输精管复通术",{"$nulls":3},"享受津贴天数"]
[null,"生育状况","□生育一孩□生育二孩□生育二孩以上",null,"流(引产)妊娠周数",{"$nulls":4},"一胞胎数"]
["就医信息","就诊医院",null,null,"门诊/住院总费用",null,null,"住院时间、生育（流、引产）时间"]
["附报资料信息","附报资料名称",{"$nulls":4},"职保","居保","生育",null,"离休","伤残"]
[{"$nulls":8},"医疗","津贴"]
[null,"1、原件：发票和医疗费用清单，附情况说明\n复印件：门诊（急诊）病历、CT、B超、心电图等检查报告、社保卡（大学生提供身份、未成年提供户口簿）、出院小结、病案首页、临时医嘱、长期医嘱、手术记录、麻醉记录（手术患者附报）",{"$nulls":4},"√","√","√",null,"√","√"]
[null,"2、生育分娩及住院流引产人员提供出院小结或出院记录复印件；门诊流产人员提供门诊病历或诊断证明书复印件；市外生育分娩的人员提交出生医学证明复印件；前期未办理生育就医登记人员提交：结婚证复印件，属生育二孩以上的应承诺本次分娩符合国家和省、市计划生育政策。",{"$nulls":7},"√"]
[null,"3、转院审批表（已办理转诊转院审批的）",{"$nulls":4},"√","√","√",null,"√","√"]
[null,"4、监护人银行借记卡（I类账户）和身份证复印件",{"$nulls":5},"√"]
[null,"5、代办人身份证复印件",{"$nulls":4},"√","√","√",null,"√","√"]
["报销费用划拨方式","□参保人社保卡金融账户："]
[null,"□个人银行借记卡、存折",null,"开户人名称："]
[{"$nulls":3},"开户银行名称："]
[{"$nulls":3},"银行卡或存折账号："]
[null,"□单位代发",null,"开户名称："]
[{"$nulls":3},"开户银行名称："]
[{"$nulls":3},"单位银行账号："]
[{"$nulls":3},"单位账号章（盖章）：\n"]
["承诺","    本人及配偶郑重承诺：本次申请    年    月    日分娩的生育（护理假）津贴，所孕为本人家庭第    个子女，符合《中华人民共和国人口与计划生育条例》和省、市计划生育规定。如承诺不实造成生育保险基金损失，由本人及配偶承担一切赔偿责任和法律后果。\n    承诺人签名（单位盖章）：                                                 年         月         日"]
[null,"    本单位/个人承诺所提供的报销材料真实合法，如有伪造或以任何方式欺诈骗取医疗生育保险待遇的，愿意承担一切后果。                                                                                                                                                                                                                                                                                                                                             承诺人签名（单位盖章）：                                                     年         月         日"]
["用人单位审核意见","经办人：                                              单位盖章\n                                                                             年         月         日"]
["受理人：",{"$nulls":5},"受理时间："]
["温馨提示： 1、参保人在提供报销资料前，请先自留发票、费用清单及出院小结等相关资料复印件，以备日后使用。\n                  2、生育津贴申报需要在承诺处加盖单位公章。"]