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["南 京 市 生 育 保 险 异 地 就 医 审 批 表"]
["单位代码",null,"单  位  名  称"]
["姓   名",null,"身 份 证 号 码"]
["个人编码",null,"异地就医医院名称"]
["生育类别","分娩（     ） 流产（     ） 上取节育环（     ） 绝育或复通（     ）"]
["异 地 就 医 原 因  ","          "]
[]
[]
[]
[]
[{"$nulls":3},"单位盖章："]
[{"$nulls":3},"年   月   日 "]
["生 育 科 意 见"]
[]
[]
[{"$nulls":3},"审批人："]
[{"$nulls":3},"    盖章："]
[{"$nulls":3},"年   月   日 "]
["异 地 就 医 医 院","异地就医医院等级："]
[]
[]
[]
[]
[{"$nulls":3},"医院盖章："]
[{"$nulls":3},"年   月   日 "]
["注：参保职工在异地分娩或实施计划生育手术后由医院医保办或医务处盖章后作为定额结算的凭证。"]

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