導語：城鎮職工醫療保險市外就醫申請書一文來源于網友上傳，不代表本站觀點，若需要原創文章可咨詢客服老師，歡迎參考。

"順德區城鎮職工醫療保險市外就醫申請書"

,,,,,,"(住院/特門)"

"參保人",,"性別",,"年齡",,"身份證號"

"參保單位:",,,,,,"社保號"

"申請就醫的醫院名稱:"

"住院時間:年月日至年月日",,,,,,"聯系電話"

"申請理由:"

,,,"申請人:",,,"年月日"

"審批意見:"

,,,,"審批人:",,"年月日"

"核對身份意見:"

"核對人:","年月",,,"日核對人:",,"年月日"

"辦事處或駐院辦公室:",,,,"經辦簽名:",,,"收表日期:"

"第二頁"

"注意事項:"

"一,辦理申請時,請附疾病診斷證明書,門診急診病歷復印件.沒有辦理長期居住異地"

"手續的,請提供臨時居住地及與居住地親人關系的證明材料."

"二,請在出院3天內持身份證辦理核對身份及報銷手續.自出院日起計超過90天不辦理"

"報銷手續的視為自動放棄,不予辦理報銷手續."

"三,按醫院級別支付標準:"

"醫院級別",,"人員身份","起付標準(元)",,"統籌基金支付比例","補充基金支付比例"

"一級醫院",,"在職",400,,"98%","90%"

,,"退休",300,,"100%"

"二級醫院",,"在職",600,,"90%"

,,"退休",500,,"93%"

"三級醫院",,"在職",1200,,"85%(惡性腫瘤,心腦疾病手術治療,肝,腎,骨髓移植按90%)"

,,"退休",1000

"四,凡轉到市外醫院的按以下比例支付:"

"1,經市內定點醫療機構轉診并經社保局核準,到市外指定醫療機構住院的,納入基本"

"醫療保險的費用按市內同等級定點醫療機構的支付比例支付;"

"2,因病情需要,經社保局核準后直接到市外指定醫療機構住院的,納入基本醫療保險"

"的費用按市內同級定點醫療機構支付比例的90%支付;"

"3,經社保局核準到市外非指定醫療機構住院的,納入基本醫療保險的費用按市內同級"

"定點醫療機構支付比例的60%支付;"

"4,未經社保局核準自行到非指定醫療機構住院的醫療費統籌基金不予支付."