| 机构名称 | {{info.fixmedins_name}} | 机构编码 | {{info.fixmedins_code}} | 医保结算级别 | |||||||||||||||||||
| 就医登记号 | {{info.psn_no}} | ||||||||||||||||||||||
| 姓名 | {{info.psn_name}} | 性别 | 男 | 女 | 出生日期 | {{info.brdy}} | 个人电脑号 | 人员类别 | |||||||||||||||
| 单位名称 | {{info.emp_name}} | 联系电话 | 身份证号 | {{info.certno}} | |||||||||||||||||||
| 住院号 | 科别 | 床号 | 入院日期 | 出院日期 | 住院天数 | ||||||||||||||||||
| 险种 | 职工基本医疗保险 | 公务员医疗补助 | 大额医疗费用补助 | 离休人员医疗保障 | 城乡居民基本医疗保险 | 城乡居民大病医疗保险 | 生育保险 | 入院第一诊断 | 出院第一诊断 | ||||||||||||||
| 业务类别 | 普通门诊 | 结算时间 | {{info.setl_time}} | ||||||||||||||||||||
| 本次就医：总费用{{info.medfee_sumamt}}元，基金支付{{info.fund_pay_sumamt}}元，个人支付{{info.psn_pay}}元。 | |||||||||||||||||||||||
| 费用名称 | 总费用 | 自费 | 部分项目自付 | 费用名称 | 总费用 | 自费 | 部分项目自付 | ||||||||||||||||
| 床位费 | {{info.bed_cost_total}} | {{info.bed_cost_self_total}} | {{info.bed_cost_part_self_total}} | 西成药 | {{info.western_medicine_cost_total}} | {{info.western_medicine_cost_self_total}} | {{info.western_medicine_cost_part_self_total}} | ||||||||||||||||
| 中药费 | 0 | 0 | 0 | 中成药 | {{info.chinese_traditional_medicine_cost_total}} | {{info.chinese_traditional_medicine_cost_self_total}} | {{info.chinese_traditional_medicine_cost_part_self_total}} | ||||||||||||||||
| 中草药 | 0 | 0 | 0 | 检查费 | {{info.check_cost_total}} | {{info.check_cost_self_total}} | {{info.check_cost_part_self_total}} | ||||||||||||||||
| 治疗费 | {{info.treat_cost_total}} | {{info.treat_cost_self_total}} | {{info.treat_cost_part_self_total}} | 放射费 | 0 | 0 | 0 | ||||||||||||||||
| 手术费 | {{info.operation_cost_total}} | {{info.operation_cost_self_total}} | {{info.operation_cost_part_self_total}} | 化验费 | {{info.laboratory_cost_total}} | {{info.laboratory_cost_self_total}} | {{info.laboratory_cost_part_self_total}} | ||||||||||||||||
| 输血费 | 0 | 0 | 0 | 输氧费 | 0 | 0 | 0 | ||||||||||||||||
| 其他 | {{info.other_cost_total}} | {{info.other_cost_self_total}} | {{info.other_cost_part_self_total}} | 麻醉费 | 0 | 0 | 0 | ||||||||||||||||
| 材料费 | {{info.material_cost_total}} | {{info.material_cost_self_total}} | {{info.material_cost_part_self_total}} | 特殊检查费 | 0 | 0 | 0 | ||||||||||||||||
| 特殊治疗费 | 0 | 0 | 0 | ||||||||||||||||||||
| 合计 | {{info.bed_cost_total + info.operation_cost_total + info.other_cost_total + info.material_cost_total + info.western_medicine_cost_total + info.chinese_traditional_medicine_cost_total + info.check_cost_total + info.laboratory_cost_total + info.treat_cost_total}} | {{info.bed_cost_self_total + info.operation_cost_self_total + info.other_cost_self_total + info.material_cost_self_total + info.western_medicine_cost_self_total + info.chinese_traditional_medicine_cost_self_total + info.check_cost_self_total + info.laboratory_cost_self_total + info.treat_cost_self_total}} | {{info.bed_cost_part_self_total + info.operation_cost_part_self_total + info.other_cost_part_self_total + info.material_cost_part_self_total + info.western_medicine_cost_part_self_total + info.chinese_traditional_medicine_cost_part_self_total + info.check_cost_part_self_total + info.laboratory_cost_part_self_total + info.treat_cost_part_self_total}} | ||||||||||||||||||||
| 基本医疗保险统筹基金支付 | {{info.hifp_pay}} | 大额基金支付 | {{info.hifob_pay}} | ||||||||||||||||||||
| 大病基金支付 | {{info.hifmi_pay}} | 补充保险基金支付 | {{info.hifes_pay}} | ||||||||||||||||||||
| 医疗救助基金支付 | {{info.maf_pay}} | 公务员基金支付 | {{info.cvlserv_pay}} | ||||||||||||||||||||
| 收款人: | 审核人: | 制单人: | 打印日期 | ||||||||||||||||||||
|
注: 1、部分项目自付金额是指基本医疗保险范围内的项目需参保人先按规定比例自付的金额。 2、此表由医院打印。 3、此表一式两份，医院、参保人各一份。 |
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| 病人家属签字: | |||||||||||||||||||||||