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["附件1："]
["安庆师范学院大学生基本医疗保险省级调剂金申请表"]
["个人基本信息(由学生本人填写)"]
["姓名",null,null,"性别",null,"政治面貌",null,"出生年月"]
["院系专业",{"$nulls":4},"年级班级",null,"学号"]
["公民身份证号码",{"$nulls":4},"本人联系电话"]
["现家庭地址及邮编",{"$nulls":6},"家庭联系                电话"]
["申请理由（由学生本人填写）"]
[]
[]
[]
["本学年支付医疗费用情况（由学生本人填写）"]
["支付医疗费用总金额（元）"]
["大学生基本医疗保险基金已补偿金额（元）"]
["个人自付金额（元）"]
["申请省级调剂金补助金额（元）"]
["审核情况"]
["学院审核意见",null,"    经审查，       同学符合调剂金补助条件。"]
[]
[null,null,"分管书记签字               单位公章                 年   月    日"]
["学生资助管理中心  审查意见",null,"    经审查，该生本学年已被认定为家庭经济困难学生。根据《安徽省大学生基本医疗保险省级调剂金管理办法（试行）》有关规定，建议省级调剂金按85%比例补助。"]
[null,null,"负责人签字",null,null,"单位公章",null,"年   月   日"]
["校医院                         审核意见",null,"    经审查，       同学符合调剂金补助条件。建议省级调剂金按    %比例补助，补助金额为         元。"]
[null,null,"负责人签字",null,null,"单位公章",null,"年   月   日"]
["说明："]
["1.此表一式两份。一份由校医院留存备查；另一份供学生申请时使用。"]
["2.此表可自行复印（正反面，A4纸规格）。"]

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