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["大学生医保零星报销申请表"]
["学校名称（盖章）：安徽警官职业学院"]
["姓名",null,null,"身份证号"]
[]
["发票金额",null,null,"发票张数",null,"入院时间"]
[{"$nulls":5},"出院时间"]
["申请异地住院或转院时间",null,null,"住院医院及所在地"]
["送 交 材 料","  1、费用明细清单（        ）张"]
[null,"  2、出院小结    （        ）张"]
[null,"  3、门诊病历    （        ）张"]
[null,"  4、证明材料    （        ）张"]
[null,"  5、处    方    （        ）张"]
[null,"  6、其     它   （        ）张"]
["退单","退回发票金额",{"$nulls":3},"发票张数"]
[null,"原因"]
[null,"初审",null,null,"复核",null,"分管领导"]
[null,"签收人",{"$nulls":3},"日期"]
["备注"]

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["大学生医保零星报销情况汇总表"]
[]
["学校名称：",null,null,"送交时间："]
["经办人：",null,"联系电话："]
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["合计","___",null,"___","___"]