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["附件1"]
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[{"$nulls":7},"备案编号："]
["______省(区、市）跨省异地就医登记备案表"]
["姓   名",null,null,"性  别",null,null,"险种","1.职工医保\n2.城乡居民医保\n3.城镇居民医保\n4.新农合"]
["人员类别","1.异地安置退休人员 \n2.异地长期居住人员\n3.常驻异地工作人员\n4.异地转诊人员",null,null,"登记类别",null,"1.新增\n2.变更"]
["社会保障号码",{"$nulls":3},"社会保障卡卡号\n(可选）"]
["参保地       家庭住址",{"$nulls":3},"异地联系地址"]
["联系电话1",{"$nulls":3},"联系电话2"]
["转往省\n（市、区）",null,null,"地区\n(市、州)",{"$nulls":3},"县（区）"]
["医疗机构","医疗机构名称",{"$nulls":5},"医疗机构级别"]
[]
[]
[]
[]
["本人\n（被委托人）\n签名",{"$nulls":5},"填表日期"]
["经办机构:",{"$nulls":3},"经办人:",null,null,"经办日期:"]

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