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["中智公司员工生育（住院分娩费用）报销申请单"]
["            请扫码关注“中智北京”公众号，查询报销进度"]
["姓名",{"$nulls":8},"身份证号码"]
["手机号码",{"$nulls":8},"电子邮箱"]
["发票最早发生年月：（       ）年（       ）月"]
["问题单据以微信、短信、邮件形式通知，请关注“中智北京”公众号。因缺少材料需要退回问题单据，邮寄费用自行承担。"]
[]
[]
["生育单据将递交到医保中心，报销款由医保中心支付到您的北京银行医保存折或您在医保中心登记的银行卡中。如您在中智有补充医疗，请填写如下账户信息，补充医疗报销款将支付到此账号中。"]
["开户银行 ",{"$nulls":6},"开户城市",{"$nulls":4},"银行账号"]
["请按如下要求填写单据信息"]
["注意事项：\n1、在北京分娩且医保已结算的住院分娩费用无需提交，只需提交全额缴费的住院分娩费用单据；\n2、如您在其他公司有补充医疗保险，请务必自行留存单据复印件，单据提交医保中心后将不再返还。            请您确认：□我已留存单据复印件  □我无补充医疗无需留存。                                           3.请参阅北京中智官网刊登的《员工报销指南》备齐、提交报销材料。\n网站浏览路径：http://www.ciicbj.com.cn→员工快速服务通道→补充医疗、商保及其他福利篇→员工报销指南→医疗费报销所需材料"]
["请按就诊先后时间填写",null,null,"就诊医院",{"$nulls":5},"单据金额",null,null,"收据张数",{"$nulls":3},"备注"]
{"$rows_empty":8}
["申请总金额（请累计收据票面总金额） ："]
["签字栏",null,null,"    本人保证上述各项填报及所提供材料均真实、准确，如有不实，本人愿意承担一切责任，如此表由他人代为填写，责任由本人承担。"]
[]
[{"$nulls":10},"申请人签字（必填）："]
[{"$nulls":10},"申请日期：",{"$nulls":3},"年",null,"月",null,"日"]

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