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["附表1"]
["疾病应急救助基金申请支付情况个案统计表\n（统计期间：2017年6月1日-2017年11月30日）"]
["  省份：（盖章）               填报人：",{"$nulls":7},"                      填报时间：    年   月   日"]
["序号","患者姓名","年龄","性别","诊断/病种","救治日期","救助医疗机构","救助类别",null,"患者总费用","申请基金金额","基金实际         支付金额","退回资金"]
[{"$nulls":7},"身份不明","无力支付"]
{"$rows_empty":9}
["合计",{"$nulls":5},"救助人次",null,null,"金额"]
["填表说明： \n1.“诊断/病种”一栏按照《需要紧急救治的急危重伤病标准及诊疗规范》给出的名称填写。                                                                                 2.“救助类别”一栏，在相对应的身份不明或无力支付下填“1”。                                                                                                                   3.患者总费用、申请基金金额、基金实际支付金额、退回资金的单位:元，精确到小数点后2位。"]