XLS《第一页》

"附件3","共两页" "东营市医疗保险普通门诊慢性病鉴定申报表",,

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"姓名",,

"性别",,

"年龄",,

"照片" "档案编号",,

"身份证号码",,

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"人员性质",,

"联系电话",,

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"单位",,

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"申报病种",,

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"提报材料清单",,

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,"材料提报人:", ,,

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,"年月日", "既往病史摘要",,

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,"专家:", ,,

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,"年月日", "鉴定现场体征检查记录",,

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,"专家:", ,,

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,"年月日", "鉴定现场辅助检查结果记录",,

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,"专家:", ,,

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,"年月日", "医学评定组初审意见",,

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"医学评定专家意见",,

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,"专家:专家:专家:",,

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, ,,

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,"年月日", "社会保险经办机构审批意见",,

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,"(盖章)", ,,

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,"年月日", "备注",,

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"填表说明:

1、"档案编号"无需申请人填写,由工作人员统一填写;

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2、"人员性质"为医疗保险参保类型,即填写"城镇职工"或"城乡居民" "

3、"单位":城镇职工填写工作单位;

城乡居民填写缴费单位;

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4、材料清单中的材料需注明所提交材料的发生日期.

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