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<title>北京市医疗保险住院费用结算支付明细表(含门诊特殊病)</title>
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北京市医疗保险住院费用结算支付明细表(含门诊特殊病)</span>
<br>
<br>
</th>
</tr>
<tr>
<td width="50%">
<p align="left">医疗机构名称：朝阳医院</p>
</td>
<td width="50%">
<p align="left">医疗机构编码: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">参保人报销地区：东城区</p>
</td></tr><tr>
<th rowspan="2" width='30'>序号</th>
<th rowspan="2" width='40'>交易<br>类别</th>
<th rowspan="2" width='40'>医疗<br>类别</th>
<th rowspan="2" width='150'>交易流水号</th>
<th rowspan="2" width='65'>姓名</th>
<th rowspan="2" width='90'>卡号/<br>手册号</th>
<th rowspan="2" width='60'>
<pre>医疗保
险参保
人员类
别</pre>
</th>
<th rowspan="2" width='90'>交易日期</th>
<th rowspan="2" width='75'>申报费用<br>总金额</th>
<th colspan="4" width='300'>支付医疗费用</th>
<th rowspan="2" width='50'>个人帐<br>户支付<br>金额</th>
<th rowspan="2" width='55'>拒付<br>金额<br>小计</th>
</tr>
<tr>
<th width='75'>(离休/<br>生育)<br>统筹支付</th>
<th width='75'>住院大额<br>支付</th>
<th width='75'>公务员<br>医疗<br>补助支付</th>
<th width='75'>支付金额<br>小计</th>
</tr><tr>
<td>1</td>
<td>普通</td>
<td>住院</td>
<td>0511000106081003267B</td>
<td>丁学清</td>
<td>10386675600S</td>
<td>
<p align="left">普/社会退休人员</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>门特</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>门特</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>门特</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>门特</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>门特</td>
<td>05110001A06071737514</td>
<td>阎连魁</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>门特</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>门特</td>
<td>05110001A06071938046</td>
<td>崔振华</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>门特</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>门特</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>门特</td>
<td>05110001A06073139457</td>
<td>阎连魁</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>黄玉兰</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>何凤阁</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>孙继良</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>门特</td>
<td>05110001A06071337204</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在职</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>门特</td>
<td>05110001A06072038285</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在职</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>门特</td>
<td>05110001A06072038286</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在职</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>门特</td>
<td>05110001A06072038287</td>
<td>曹彬</td>
<td>10464531200S</td>
<td>
<p align="left">普/在职</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>黄绍雄</td>
<td>10444483400S</td>
<td>
<p align="left">普/在职</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">门特小计(14笔)：</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">住院小计(5笔)：</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">小计：19笔</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">参保人报销地区：西城区</p>
</td></tr><tr>
<th rowspan="2" width='30'>序号</th>
<th rowspan="2" width='40'>交易<br>类别</th>
<th rowspan="2" width='40'>医疗<br>类别</th>
<th rowspan="2" width='150'>交易流水号</th>
<th rowspan="2" width='65'>姓名</th>
<th rowspan="2" width='90'>卡号/<br>手册号</th>
<th rowspan="2" width='60'>
<pre>医疗保
险参保
人员类
别</pre>
</th>
<th rowspan="2" width='90'>交易日期</th>
<th rowspan="2" width='75'>申报费用<br>总金额</th>
<th colspan="4" width='300'>支付医疗费用</th>
<th rowspan="2" width='50'>个人帐<br>户支付<br>金额</th>
<th rowspan="2" width='55'>拒付<br>金额<br>小计</th>
</tr>
<tr>
<th width='75'>(离休/<br>生育)<br>统筹支付</th>
<th width='75'>住院大额<br>支付</th>
<th width='75'>公务员<br>医疗<br>补助支付</th>
<th width='75'>支付金额<br>小计</th>
</tr><tr>
<td>1</td>
<td>普通</td>
<td>门特</td>
<td>05110001A06041024315</td>
<td>芦川</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>门特</td>
<td>05110001A06050927652</td>
<td>芦川</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>郭春华</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">门特小计(2笔)：</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">住院小计(1笔)：</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">小计：3笔</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">参保人报销地区：崇文区</p>
</td></tr><tr>
<th rowspan="2" width='30'>序号</th>
<th rowspan="2" width='40'>交易<br>类别</th>
<th rowspan="2" width='40'>医疗<br>类别</th>
<th rowspan="2" width='150'>交易流水号</th>
<th rowspan="2" width='65'>姓名</th>
<th rowspan="2" width='90'>卡号/<br>手册号</th>
<th rowspan="2" width='60'>
<pre>医疗保
险参保
人员类
别</pre>
</th>
<th rowspan="2" width='90'>交易日期</th>
<th rowspan="2" width='75'>申报费用<br>总金额</th>
<th colspan="4" width='300'>支付医疗费用</th>
<th rowspan="2" width='50'>个人帐<br>户支付<br>金额</th>
<th rowspan="2" width='55'>拒付<br>金额<br>小计</th>
</tr>
<tr>
<th width='75'>(离休/<br>生育)<br>统筹支付</th>
<th width='75'>住院大额<br>支付</th>
<th width='75'>公务员<br>医疗<br>补助支付</th>
<th width='75'>支付金额<br>小计</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/社会退休人员</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>门特</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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