導語：城鎮(zhèn)職工醫(yī)療保險市外就醫(yī)申請書一文來源于網(wǎng)友上傳，不代表本站觀點，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:"

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

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

"二,請在出院3天內(nèi)持身份證辦理核對身份及報銷手續(xù).自出院日起計超過90天不辦理"

"報銷手續(xù)的視為自動放棄,不予辦理報銷手續(xù)."

"三,按醫(yī)院級別支付標準:"

"醫(yī)院級別",,"人員身份","起付標準(元)",,"統(tǒng)籌基金支付比例","補充基金支付比例"

"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)定點醫(yī)療機構轉(zhuǎn)診并經(jīng)社保局核準,到市外指定醫(yī)療機構住院的,納入基本"

"醫(yī)療保險的費用按市內(nèi)同等級定點醫(yī)療機構的支付比例支付;"

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

"的費用按市內(nèi)同級定點醫(yī)療機構支付比例的90%支付;"

"3,經(jīng)社保局核準到市外非指定醫(yī)療機構住院的,納入基本醫(yī)療保險的費用按市內(nèi)同級"

"定點醫(yī)療機構支付比例的60%支付;"

"4,未經(jīng)社保局核準自行到非指定醫(yī)療機構住院的醫(yī)療費統(tǒng)籌基金不予支付."