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["南平市职工医疗互助活动住院补助金申请审批表"]
[]
["申请人所在单位"]
[]
["申请人姓名",{"$nulls":4},"身份证号"]
[]
["申请人联系电话",{"$nulls":4},"就诊医院"]
[]
["医保类型",null,"  £职工医保",null,null,"就诊类型",null,"£辖区内    £自行转外"]
[]
[null,null,"  £城乡居民医保",{"$nulls":4},"£正常转外   £异地安置"]
[]
["本次住院时间",null,"   年  月  日至     年  月  日",{"$nulls":3},"住院\n天数",null,"住院\n总费用"]
[]
["申请人开户银行名称：                        银行账号："]
["申请人（签字）：    \n                       ",{"$nulls":4},"申请人所在单位工会意见（加盖工会章）：                                    \n                            "]
[]
[]
[]
["                      年    月    日",{"$nulls":4},"                         年    月    日 "]
["以上由申请人和申请人单位填写"]
["已补助\n金额","大写：  万    仟    佰    拾    元    角    分（ ￥      ）",{"$nulls":7},"已补助\n次数"]
[]
["本次补助金额","大写:   万    仟    佰    拾    元    角    分 ( ￥      ）"]
[]
["服务   中心   审核   意见\n（签章）","初审：",{"$nulls":4},"复核："]
[]
[null,"                   年    月    日",{"$nulls":4},"                   年    月    日"]
[null,"部门领导审批：\n"]
[]
[null,"                                                         年    月    日"]
[null,"分管领导审批： "]
[]
[]
[null,"                                                         年    月    日"]
["附注：","1、此表可以在南平市总工会网站下载，下载网址：http://www.npgh.org/，资料中\n   心内。"]
[null,"2、此表一式一份报送，根据档案用水笔填写或钢笔正确填写，要求字迹清晰。"]
[null,"3、空白表可复印使用，复印时使用A4纸。"]

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