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["异地就医登记备案表"]
["姓名",null,"性别",null,"险种","□职工医保             □城乡居民医保"]
["人员类别","□异地安置退休人员",null,null,"登记类别","□新增       □变更"]
[null,"□异地长期居住人员"]
[null,"□常驻异地工作人员"]
[null,"□异地转诊人员"]
[null,"□其他："]
["身份证号码"]
["参保地联系地址",{"$nulls":3},"就医地联系地址"]
["联系电话1",{"$nulls":3},"联系电话2"]
["转往省（市、区）",null,"地区（市、州）",null,"县（区）"]
["温馨提示"]
["  1.跨省异地就医执行就医地目录、参保地起付线、封顶线及支付比例。因各地目录差异，直接结算与回参保地报销可能存在待遇差，属于正常现象。                                                           "]
["  2.办理备案时直接备案到就医地市或省份。参保人员根据病情、居住地、交通等情况，自主选择就医地开通的跨省定点医疗机构住院就医。"]
["  3.到北京、天津、上海、重庆、海南、西藏和新疆生产建设兵团就医，备案到就医省份即可。"]
["  4.未按规定办理登记备案手续，或在就医地非跨省定点医疗机构发生的医疗费用，按参保地有关规定办理。"]
["□本人   □被委托人     签名",{"$nulls":3},"填表日期"]
["经办机构：",null,"联系电话：",null,"经办人：","  经办日期："]