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["附件2"]
["蓝田县医疗救助申请审批表"]
["编号：",{"$nulls":8},"           申请日期："]
["申请人姓名",null,null,"性别",null,"年龄",null,"身份证号码"]
["家庭住址",{"$nulls":6},"联系电话"]
["救助对象类别（√）",null,"城市“三无”人员",null,null,"城市低保对象",{"$nulls":3},"城市低收入对象",{"$nulls":4},"城市因病致贫对象"]
[null,null,"农村五保对象",null,null,"农村低保对象",{"$nulls":3},"农村因病致贫对象",{"$nulls":4},"其他"]
["就诊医院\n名称",null,null,"诊断病情",null,null,"住院起止时间"]
["医疗费用\n总支出",null,null,"基本医疗\n保险报销",null,null,"大病保险\n报销",null,null,"其他减免\n（报销）",null,null,"个人自付"]
["申请理由","  "]
["公示日期",{"$nulls":5},"公示经办人签字"]
["家庭成员\n基本信息（此项特困供养、低保、低收入对象不再填写）","关系","姓名","性别","出生年月","婚姻状况","身份证号码",null,"户籍地",null,"实际居住地"]
{"$rows_empty":9}
["                                                                                                                -14-"]

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["家庭成员\n财产信息（此项特困供养、低保、低收入对象不再填写）","关系","姓名","货币财产",null,null,"房产",null,null,"机动车辆"]
[{"$nulls":3},"申请之日前\n12个月收入","现金及\n存款","有价证券\n等市值","套数","面积","房屋性质","品牌型号","购置时间",null,null,"购车价格",null,"车辆性质"]
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["合计"]
["以下由镇民政部门填写"]
["货币财产\n认定情况",null,null,"房产认定 情况",null,null,"机动车辆 \n认定情况",null,null,"其他   认定\n情况",null,null,"入户调查人："]
[{"$nulls":12},"民主评议召集人："]
[]
[{"$nulls":12},"公示负责人："]
["申请之日前12个月家庭总收入核定",{"$nulls":5},"本年度人居可支配收入核定",null,null," ",null,null,"          年  月  日"]
["医疗费用\n总支出核定",null,null,"基本医疗\n保险报销\n核定",null,null,"大病保险\n报销核定",null,null,"其他减免（报销）\n核定",null,null,"个人  自负\n核定"]
["镇（街办）审核意见",{"$nulls":5},"区县\n民政\n部门\n审批\n意见","根据有关规定，经审核，同意按照医疗救助标准给予救助，救助金额               元。\n\n                                                           经办人：            审核人 ：                 年   月   日"]
[null,"镇街民政工作站核查负责人："]
[null,"                               年   月   日"]
["  -15-"]

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