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["附表3"]
["西安市城镇职工基本医疗保险门诊慢性病申请鉴定表"]
[{"$nulls":3},"公务员",{"$nulls":4},"企事业"]
[]
["                       年      月     日"]
["姓    名",null,null,"性别",null,"年龄",null,null,"医保编号",null,"照片"]
["工作单位",{"$nulls":7},"单位编号"]
["IC卡编号",{"$nulls":7},"联系电话"]
["家庭住址"]
["选择定点医疗机构"]
["申请病种"]
["简要病史阳性特征化验报告检查报告"]
[null,"申请人："]
[null,"                                         年       月       日"]
["单位意见","情况属实。   "]
[null,"                签章："]
[null,"                                             年        月      日    "]
["鉴定情况","   "]
[null,"                     经办人："]
[null,"                                              年        月      日    "]
["备  注"]

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