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[null,"            北京市医疗保险异地安置（长期驻外）人员\n                异地定点医疗机构变更登记表"]
[]
[null,"姓名",null,null,"性别",null,"年龄",null,null,"人员类别"]
[]
[null,"身份证号码",{"$nulls":4},"工作单位"]
[]
[null,"本市住址",{"$nulls":4},"联系人",null,null,"联系电话"]
[]
[null,"居外详细地址"]
[]
[null,"居外联系人",{"$nulls":4},"联系电话",null,null,"居外邮编"]
[]
[null,"原选定\n异地医院",1,{"$nulls":6},"医院等级"]
[]
[null,null,2]
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[null,"变更后\n异地医院",1,{"$nulls":6},"医院等级"]
[]
[null,null,2]
[]
[null,"变更后异地医院1盖章        变更后异地医院2盖章",{"$nulls":5},"异地医疗保险部门盖章\n\n\n\n                        \n                年   月    日"]
[]
[]
[]
[]
[]
[null,"本人签字：                                                            年   月    日"]
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[null,"单位/社保所意见（城镇居民办理时此栏不必填写、不必盖章）：\n\n单位/社保所经办人：              联系电话：               单位盖章      年   月   日\n\n\n"]
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[]
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[null,"区、县社保经办机构意见：\n\n    办理日期     年    月    日，自办理复审之日起生效。\n   \n经办登记人员：        经办审核人员：        区、县社保经办机构盖章：    年   月   日"]
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[]
[]
[]
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[null,"\n注：1、此表一式两份，区、县社保经办机构和参保人员各留存一份。\n\n    2、人员类别栏填写“城镇职工（在职/退休）、城镇居民、超转人员”。\n\n    3、城镇职工、超转人员由用人单位或社保所到区、县社保经办部门办理，城镇居民可由参保人员\n\n       或家属持此表到区、县社保经办部门办理。需变更异地安置定点医疗机构或异地安置定点医疗\n\n       机构取消当地医保定点医疗机构资格时，参保人员填写此表，及时办理变更登记。\n\n"]

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