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["附件1："]
["北京市基本医疗保险跨省异地就医住院医疗费用\n直接结算备案登记表"]
["单位名称（章）："]
["统一社会信用代码（社保登记号)："]
["姓   名",null,null,"性  别",null,null,"险种","□.职工医保\n□.城乡居民医保"]
["人员类别","    □.异地安置退休人员 \n    □.异地长期居住人员\n    □.常驻异地工作人员\n    □.异地转诊人员",{"$nulls":3},"登记类别","□.新增\n□.变更\n    □.取消备案"]
["社会保障号码\n（身份证号）",{"$nulls":4},"社会保障卡号\n(可选）"]
["参保地       家庭住址",{"$nulls":4},"异地联系地址"]
["联系电话1",{"$nulls":4},"联系电话2"]
["转往省\n（市、区）",null,null,"地区\n(市、州)",null,null,"县（区）"]
["定点医疗机构","定点医疗机构代码",{"$nulls":3},"定点医疗机构名称"]
["异地定点\n医疗机构",1]
[null,2]
["本市定点\n医疗机构"]
["本人签字",{"$nulls":4},"填表日期"]
[]
["单位经办人签字",null,null,"联系电话",null,null,"经办日期"]
["社保经办机构："]
["办理日期     年    月    日，自办理备案登记次日起生效。"]
["经办人员：",null,null,"社保经办机构盖章：",null,null," 年  月  日"]

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