城镇职工医疗保险市外就医申请书

"顺德区城镇职工医疗保险市外就医申请书"

,,,,,,"(住院/特门)"

"参保人",,"性别",,"年龄",,"身份证号"

"参保单位:",,,,,,"社保号"

"申请就医的医院名称:"

"住院时间:年月日至年月日",,,,,,"联系电话"

"申请理由:"

,,,"申请人:",,,"年月日"

"审批意见:"

,,,,"审批人:",,"年月日"

"核对身份意见:"

"核对人:","年月",,,"日核对人:",,"年月日"

"办事处或驻院办公室:",,,,"经办签名:",,,"收表日期:"

"第二页"

"注意事项:"

"一,办理申请时,请附疾病诊断证明书,门诊急诊病历复印件.没有办理长期居住异地"

"手续的,请提供临时居住地及与居住地亲人关系的证明材料."

"二,请在出院3天内持身份证办理核对身份及报销手续.自出院日起计超过90天不办理"

"报销手续的视为自动放弃,不予办理报销手续."

"三,按医院级别支付标准:"

"医院级别",,"人员身份","起付标准(元)",,"统筹基金支付比例","补充基金支付比例"

"一级医院",,"在职",400,,"98%","90%"

,,"退休",300,,"100%"

"二级医院",,"在职",600,,"90%"

,,"退休",500,,"93%"

"三级医院",,"在职",1200,,"85%(恶性肿瘤,心脑疾病手术治疗,肝,肾,骨髓移植按90%)"

,,"退休",1000

"四,凡转到市外医院的按以下比例支付:"

"1,经市内定点医疗机构转诊并经社保局核准,到市外指定医疗机构住院的,纳入基本"

"医疗保险的费用按市内同等级定点医疗机构的支付比例支付;"

"2,因病情需要,经社保局核准后直接到市外指定医疗机构住院的,纳入基本医疗保险"

"的费用按市内同级定点医疗机构支付比例的90%支付;"

"3,经社保局核准到市外非指定医疗机构住院的,纳入基本医疗保险的费用按市内同级"

"定点医疗机构支付比例的60%支付;"

"4,未经社保局核准自行到非指定医疗机构住院的医疗费统筹基金不予支付."