'医疗费用报销申请单 / 保险理赔核算清单'
'理赔编号 '${claimNo}' 申请日期 '${applyDate}' 保险公司 '${insurerName}
| '理赔编号 / CLAIM NO.' | ${claimNo} | '申请日期 / DATE' | ${applyDate} |
| '保险公司 / 机构' | ${insurerName} | '保单号 / 险种' | ${policyNo} |
| '被保险人 / 投保人' | ${insuredInfo} | '身份证号 / 联系手机' | ${idCard} |
| '就诊医院 / 科室' | ${hospitalInfo} | '出险原因 / 诊断' | ${accidentInfo} |
| '申请赔付金额' | ${claimAmount} | '开户银行 / 账号' | ${bankInfo} |
| '理赔核算明细' |
| '序号' | '费用类别' | '申请金额' | '医保已付' | '免赔额扣除' | '核定赔付额' | '核定结论' |
|---|---|---|---|---|---|---|
| ${itemName1} | ${itemSpec1} | ${itemUnit1} | ${itemQty1} | ${itemPrice1} | ${itemAmount1} | ${itemTax1} |
| ${itemName2} | ${itemSpec2} | ${itemUnit2} | ${itemQty2} | ${itemPrice2} | ${itemAmount2} | ${itemTax2} |
| ${itemName3} | ${itemSpec3} | ${itemUnit3} | ${itemQty3} | ${itemPrice3} | ${itemAmount3} | ${itemTax3} |
| ${itemName4} | ${itemSpec4} | ${itemUnit4} | ${itemQty4} | ${itemPrice4} | ${itemAmount4} | ${itemTax4} |
| ${itemName5} | ${itemSpec5} | ${itemUnit5} | ${itemQty5} | ${itemPrice5} | ${itemAmount5} | ${itemTax5} |
| ${itemName6} | ${itemSpec6} | ${itemUnit6} | ${itemQty6} | ${itemPrice6} | ${itemAmount6} | ${itemTax6} |
| '核算合计' | '—' | '￥'${totalFee} | '￥'${fundPaid} | '￥'${deductible} | '￥'${totalAmount} | '—' |
| ' ' | '理赔核算结论' |
${totalLine}
| ' ' | '备注 / REMARKS' |
${remark}
// 签章区：right| '本联次加盖印章后有效，扫码可验真' | '（医疗机构公章 / 财务专用章占位）' '（骑缝章 / 二维码占位）' |
| ' ' | '医疗机构：'${insurerName} '骑缝章沿右边线骑缝加盖' |
| ' ' | '出具日期：'${applyDate} '二维码打印于右上角方框内' |
| '申请人：'${applicantSign} | '理赔经办：'${operator} | '核赔人：'${claimOfficer} |