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["协议定点医药机构信息变更表"]
[" "]
["单位公章：                                                           年     月     日"]
["机构名称",{"$nulls":5},"医保编码\n(六位)"]
["地址",{"$nulls":5},"国家编码"]
["机构经办人",null,null,null,"联系电话"]
["执业许可证号",null,null,null,"统一社会信用代码"]
["GSP证书编号（药店）",null,null,null,"床位(牙椅)\n（医院）",null,"床位      (张)  牙椅      (张)"]
["信息项变更原因"]
[]
["拟变更事项",null,"变更前信息",null,null,"变更后信息"]
["机构名称"]
["机构地址"]
["法定代表人\n（姓名+身份证号）"]
["床位(牙椅)"]
["执业药师"]
["其他"]
["卫生技术人员情况表（一级以下定点医疗机构填写）"]
["执业医师",null,"共   名，其中：高级职称  名，中级职称   名。"]
["护士",null,"共    名。"]
["姓名","身份证号",null,"资格证号",null,null,"执业证号","本人签字"]
{"$rows_empty":7}
[" 可自行添加"]
["执业药师情况表（定点零售药店填写）"]
["执业药师姓名",null,"身份证号",{"$nulls":4},"本人签字"]
[]
[]
["可自行添加"]
["承诺：依照医保定点要求，本单位以上所提供的资料、信息真实完整有效。如提供虚假资料、信息，将承担由此造成的一切后果。"]
["                            法定代表人本人签字："]
["医保中心经办人：                  医保中心复核人：\t"]
["注：1.变更原因写具体情况；"]
["2.拟变更事项只填写需变更的项目即可；"]
["3.此表格可双面打印；"]
["4.变更表每页须加盖公章。"]

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