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["定点医药机构开户信息备案表"]
["定点医药机构（公章）：",null,null,null,"       填报日期：     年     月     日"]
["定点医药机构名称："]
["定点医药机构地址："]
["定点医药机构编码(医保六位码)：",{"$nulls":4},"医保中心\n定点医药机构服务处\n（签章）\n\n\n经办人：     "]
["定点医药机构编码(国码)："]
["执业许可证号："]
["统一社会信用代码："]
["GSP证书编号（药店）："]
["法定代表人(本人签字）："]
["经办人：              ",null,"电话："]
["定点医药机构服务处：68966720"]
["开户信息","开户名称"]
[null,"开户行"]
[null,"账号",{"$nulls":4},"联行号"]
["变更后        开户信息","开户名称"]
[null,"开户行"]
[null,"账号",{"$nulls":4},"联行号"]
["账户变更原因："]
["\n定点医药机构开户预留印鉴（财务章、法人章）",null,null,null,"\n医保中心基金财务处（签章）\n\n\n\n\n\n\n\n经办人："]
[]
[]
["基金财务处：68966636"]
["注:1.本表一式两份，定点医药机构服务处、基金财务处各留存一份。\n   2.医保中心定点医药机构服务处（签章）、医保中心基金财务处（签章）为医保中心相应处室填写，医药机构无需填写。其余表中空项为定点医药机构填写。"]

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