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<title>北京市醫療保險住院費用結算支付明細表(含門診特殊病)</title>
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北京市醫療保險住院費用結算支付明細表(含門診特殊病)</span>
<br>
<br>
</th>
</tr>
<tr>
<td width="50%">
<p align="left">醫療機構名稱：朝陽醫院</p>
</td>
<td width="50%">
<p align="left">醫療機構編碼:05110001</p>
</td>
</tr>
</table>
<table width="970" align="center" border="1" borderColorDark="#ffffff" borderColorLight="#aaaaaa" cellPadding="1" cellSpacing="0"><tr bgcolor='#dddddd'><td colspan="15">
<p align="left">參保人報銷地區：東城區</p>
</td></tr><tr>
<th rowspan="2" width='30'>序號</th>
<th rowspan="2" width='40'>交易<br>類別</th>
<th rowspan="2" width='40'>醫療<br>類別</th>
<th rowspan="2" width='150'>交易流水號</th>
<th rowspan="2" width='65'>姓名</th>
<th rowspan="2" width='90'>卡號/<br>手冊號</th>
<th rowspan="2" width='60'>
<pre>醫療保
險參保
人員類
別</pre>
</th>
<th rowspan="2" width='90'>交易日期</th>
<th rowspan="2" width='75'>申報費用<br>總金額</th>
<th colspan="4" width='300'>支付醫療費用</th>
<th rowspan="2" width='50'>個人帳<br>戶支付<br>金額</th>
<th rowspan="2" width='55'>拒付<br>金額<br>小計</th>
</tr>
<tr>
<th width='75'>(離休/<br>生育)<br>統籌支付</th>
<th width='75'>住院大額<br>支付</th>
<th width='75'>公務員<br>醫療<br>補助支付</th>
<th width='75'>支付金額<br>小計</th>
</tr><tr>
<td>1</td>
<td>普通</td>
<td>住院</td>
<td>0511000106081003267B</td>
<td>丁學清</td>
<td>10386675600S</td>
<td>
<p align="left">普/社會退休人員</p>
</td>
<td>2006-08-10</td>
<td>22504.2</td>
<td>22504.2</td>
<td>0</td>
<td>0</td>
<td>22504.2</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>2</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071136773</td>
<td>田桂苓</td>
<td>10045852200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-11</td>
<td>3933.55</td>
<td>3915.5</td>
<td>18.05</td>
<td>0</td>
<td>3933.55</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>3</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071136836</td>
<td>田桂苓</td>
<td>10045852200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-11</td>
<td>1061.42</td>
<td>0</td>
<td>1061.42</td>
<td>0</td>
<td>1061.42</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>4</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071237007</td>
<td>田桂苓</td>
<td>10045852200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-12</td>
<td>1016.68</td>
<td>0</td>
<td>1016.68</td>
<td>0</td>
<td>1016.68</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>5</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071337141</td>
<td>田桂苓</td>
<td>10045852200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-13</td>
<td>965.94</td>
<td>0</td>
<td>965.94</td>
<td>0</td>
<td>965.94</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>6</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071737514</td>
<td>閻連魁</td>
<td>10004324800S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-17</td>
<td>3346.77</td>
<td>945.98</td>
<td>2400.79</td>
<td>0</td>
<td>3346.77</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>7</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071837761</td>
<td>田桂苓</td>
<td>10045852200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-18</td>
<td>42.29</td>
<td>0</td>
<td>42.29</td>
<td>0</td>
<td>42.29</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>8</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071938046</td>
<td>崔振華</td>
<td>10434613200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-19</td>
<td>8654.21</td>
<td>2862.17</td>
<td>5792.04</td>
<td>0</td>
<td>8654.21</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>9</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06072538787</td>
<td>田桂苓</td>
<td>10045852200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-25</td>
<td>368.99</td>
<td>0</td>
<td>368.99</td>
<td>0</td>
<td>368.99</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>10</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06072839320</td>
<td>宋黎生</td>
<td>10321931800S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-28</td>
<td>11644.74</td>
<td>0</td>
<td>11644.74</td>
<td>0</td>
<td>11644.74</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>11</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06073139457</td>
<td>閻連魁</td>
<td>10004324800S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-31</td>
<td>749.37</td>
<td>0</td>
<td>749.37</td>
<td>0</td>
<td>749.37</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>12</td>
<td>普通</td>
<td>住院</td>
<td>0511000106080203256B</td>
<td>黃玉蘭</td>
<td>10094087200S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-08-02</td>
<td>5903.72</td>
<td>5903.72</td>
<td>0</td>
<td>0</td>
<td>5903.72</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>13</td>
<td>普通</td>
<td>住院</td>
<td>05110001A06061332922</td>
<td>何鳳閣</td>
<td>10212029400S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-06-13</td>
<td>164844.39</td>
<td>120715.87</td>
<td>44128.52</td>
<td>0</td>
<td>164844.39</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>14</td>
<td>普通</td>
<td>住院</td>
<td>05110001A06072138420</td>
<td>孫繼良</td>
<td>10003723900S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-07-21</td>
<td>7627.14</td>
<td>4020.76</td>
<td>3606.38</td>
<td>0</td>
<td>7627.14</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>15</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06071337204</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在職</p>
</td>
<td>2006-07-13</td>
<td>5383.28</td>
<td>0</td>
<td>5383.28</td>
<td>0</td>
<td>5383.28</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>16</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06072038285</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在職</p>
</td>
<td>2006-07-20</td>
<td>3277.32</td>
<td>0</td>
<td>3277.32</td>
<td>0</td>
<td>3277.32</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>17</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06072038286</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在職</p>
</td>
<td>2006-07-20</td>
<td>621.18</td>
<td>0</td>
<td>621.18</td>
<td>0</td>
<td>621.18</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>18</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06072038287</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在職</p>
</td>
<td>2006-07-20</td>
<td>561.88</td>
<td>0</td>
<td>561.88</td>
<td>0</td>
<td>561.88</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>19</td>
<td>普通</td>
<td>住院</td>
<td>05110001A06051728914</td>
<td>黃紹雄</td>
<td>10444483400S</td>
<td>
<p align="left">普/在職</p>
</td>
<td>2006-05-17</td>
<td>77772</td>
<td>45553.61</td>
<td>32218.39</td>
<td>0</td>
<td>77772</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td colspan="8">
<p align="right">門特小計(14筆)：</p>
</td>
<td>41627.62</td>
<td>7723.65</td>
<td>33903.97</td>
<td>0</td>
<td>41627.62</td>
<td>0</td>
<td>0</td>
</tr>
<tr>
<td colspan="8">
<p align="right">住院小計(5筆)：</p>
</td>
<td>278651.45</td>
<td>198698.16</td>
<td>79953.29</td>
<td>0</td>
<td>278651.45</td>
<td>0</td>
<td>0</td>
</tr>
<tr>
<td colspan="8">
<p align="left">小計：19筆</p>
</td>
<td>320279.07</td>
<td>206421.81</td>
<td>113857.26</td>
<td>0</td>
<td>320279.07</td>
<td>0</td>
<td>0</td>
</tr><tr bgcolor='#dddddd'><td colspan="15">
<p align="left">參保人報銷地區：西城區</p>
</td></tr><tr>
<th rowspan="2" width='30'>序號</th>
<th rowspan="2" width='40'>交易<br>類別</th>
<th rowspan="2" width='40'>醫療<br>類別</th>
<th rowspan="2" width='150'>交易流水號</th>
<th rowspan="2" width='65'>姓名</th>
<th rowspan="2" width='90'>卡號/<br>手冊號</th>
<th rowspan="2" width='60'>
<pre>醫療保
險參保
人員類
別</pre>
</th>
<th rowspan="2" width='90'>交易日期</th>
<th rowspan="2" width='75'>申報費用<br>總金額</th>
<th colspan="4" width='300'>支付醫療費用</th>
<th rowspan="2" width='50'>個人帳<br>戶支付<br>金額</th>
<th rowspan="2" width='55'>拒付<br>金額<br>小計</th>
</tr>
<tr>
<th width='75'>(離休/<br>生育)<br>統籌支付</th>
<th width='75'>住院大額<br>支付</th>
<th width='75'>公務員<br>醫療<br>補助支付</th>
<th width='75'>支付金額<br>小計</th>
</tr><tr>
<td>1</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06041024315</td>
<td>蘆川</td>
<td>10253248900S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-04-10</td>
<td>3771.04</td>
<td>3771.04</td>
<td>0</td>
<td>0</td>
<td>3771.04</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>2</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06050927652</td>
<td>蘆川</td>
<td>10253248900S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-05-09</td>
<td>2075.48</td>
<td>2075.48</td>
<td>0</td>
<td>0</td>
<td>2075.48</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>3</td>
<td>普通</td>
<td>住院</td>
<td>0511000106080403609B</td>
<td>郭春華</td>
<td>10322502000S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-08-04</td>
<td>4487</td>
<td>4487</td>
<td>0</td>
<td>0</td>
<td>4487</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td colspan="8">
<p align="right">門特小計(2筆)：</p>
</td>
<td>5846.52</td>
<td>5846.52</td>
<td>0</td>
<td>0</td>
<td>5846.52</td>
<td>0</td>
<td>0</td>
</tr>
<tr>
<td colspan="8">
<p align="right">住院小計(1筆)：</p>
</td>
<td>4487</td>
<td>4487</td>
<td>0</td>
<td>0</td>
<td>4487</td>
<td>0</td>
<td>0</td>
</tr>
<tr>
<td colspan="8">
<p align="left">小計：3筆</p>
</td>
<td>10333.52</td>
<td>10333.52</td>
<td>0</td>
<td>0</td>
<td>10333.52</td>
<td>0</td>
<td>0</td>
</tr><tr bgcolor='#dddddd'><td colspan="15">
<p align="left">參保人報銷地區：崇文區</p>
</td></tr><tr>
<th rowspan="2" width='30'>序號</th>
<th rowspan="2" width='40'>交易<br>類別</th>
<th rowspan="2" width='40'>醫療<br>類別</th>
<th rowspan="2" width='150'>交易流水號</th>
<th rowspan="2" width='65'>姓名</th>
<th rowspan="2" width='90'>卡號/<br>手冊號</th>
<th rowspan="2" width='60'>
<pre>醫療保
險參保
人員類
別</pre>
</th>
<th rowspan="2" width='90'>交易日期</th>
<th rowspan="2" width='75'>申報費用<br>總金額</th>
<th colspan="4" width='300'>支付醫療費用</th>
<th rowspan="2" width='50'>個人帳<br>戶支付<br>金額</th>
<th rowspan="2" width='55'>拒付<br>金額<br>小計</th>
</tr>
<tr>
<th width='75'>(離休/<br>生育)<br>統籌支付</th>
<th width='75'>住院大額<br>支付</th>
<th width='75'>公務員<br>醫療<br>補助支付</th>
<th width='75'>支付金額<br>小計</th>
</tr><tr>
<td>1</td>
<td>普通</td>
<td>住院</td>
<td>05110001A06080340060</td>
<td>李秀容</td>
<td>10053945300S</td>
<td>
<p align="left">普/社會退休人員</p>
</td>
<td>2006-08-03</td>
<td>4764</td>
<td>4764</td>
<td>0</td>
<td>0</td>
<td>4764</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
<tr>
<td>2</td>
<td>普通</td>
<td>門特</td>
<td>05110001A06080239812</td>
<td>宋玲玲</td>
<td>10154997700S</td>
<td>
<p align="left">普/退休</p>
</td>
<td>2006-08-02</td>
<td>5982.09</td>
<td>0</td>
<td>5982.09</td>
<td>0</td>
<td>5982.09</td>
<td>0</td>
<td>0</td>
</tr><tr></tr>
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