{"text_format":"3","workbook":"xlsx","n_sheets":3,"sheets":["封面","承诺书","申请表"],"read":"whole","date_system":"1900"}

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["附件1"]
["青岛市社会医疗保险“双通道”\n定点零售药店申请表"]
["         定点零售药店名称（加盖公章）                            \n\n         法定代表人（签章）                                         \n\n\n\n\n\n\n\n\n\n\n\n"]
["青岛市医疗保险事业中心制"]

{"sheet":"承诺书","index":1,"n_rows":7,"n_cols":1,"rows_kept":7,"merged":[[0,0,0,8],[1,0,1,8],[2,0,2,8],[3,5,3,8],[6,0,6,8]]}
["\n 青岛市社会医疗保险“双通道”定点零售药店\n承   诺   书\n   \n\n"]
["    本单位自查符合青岛市社会医疗保险双通道药店申请条件，自愿承担医保双通道业务服务。承诺无药品经销、医保管理重大违规或失信行为，所提供的所有材料真实、完整、有效。如承诺内容和材料与事实不符，愿接受医保经办机构解除服务协议、追缴相关医疗保险费用等处理，并承担由此造成的一切后果。\n    特此承诺。\n\n\n\n\n      "]
["                定点零售药店名称（盖章）：\n\n\n                法定代表人（签章）：\n\n\n                负责人（签章）：\n\n\n\n                                         年   月   日"]
[]
[]
[]
["注：公章应为公安备案公章；签章为签字+盖章"]

{"sheet":"申请表","index":2,"n_rows":54,"n_cols":9,"rows_kept":54,"merged":[[0,0,0,8],[1,7,1,8],[2,0,2,2],[2,3,2,4],[2,5,2,6],[2,7,2,8],[3,0,3,2],[3,3,3,4],[3,5,3,6],[3,7,3,8],[4,0,4,2],[4,3,4,5],[4,6,4,7],[5,0,5,2],[5,3,5,4],[5,5,5,6],[5,7,5,8],[6,0,6,2],[6,3,6,5],[6,6,6,7],[7,0,7,2],[7,3,7,5],[7,6,7,7],[8,1,8,2],[8,4,8,5],[8,7,8,8],[9,0,9,8],[10,0,11,0],[10,1,11,1],[10,2,11,2],[10,3,11,3],[10,4,11,6],[10,7,11,7],[10,8,11,8],[12,4,12,6],[13,4,13,6],[14,4,14,6],[15,0,16,8],[17,0,18,0],[17,1,18,1],[17,2,18,2],[17,3,18,3],[17,4,18,4],[17,5,18,6],[17,7,18,8],[19,1,19,8],[20,5,20,6],[20,7,20,8],[21,5,21,6],[21,7,21,8],[22,5,22,6],[22,7,22,8],[23,5,23,6],[23,7,23,8],[24,5,24,6],[24,7,24,8],[25,5,25,6],[25,7,25,8],[26,5,26,6],[26,7,26,8],[27,5,27,6],[27,7,27,8],[28,5,28,6],[28,7,28,8],[29,5,29,6],[29,7,29,8],[30,5,30,6],[30,7,30,8],[31,5,31,6],[31,7,31,8],[32,5,32,6],[32,7,32,8],[33,5,33,6],[33,7,33,8],[34,5,34,6],[34,7,34,8],[35,5,35,6],[35,7,35,8],[36,5,36,6],[36,7,36,8],[37,5,37,6],[37,7,37,8],[38,5,38,6],[38,7,38,8],[39,5,39,6],[39,7,39,8],[40,5,40,6],[40,7,40,8],[41,5,41,6],[41,7,41,8],[42,5,42,6],[42,7,42,8],[43,5,43,6],[43,7,43,8],[44,5,44,6],[44,7,44,8],[45,5,45,6],[45,7,45,8],[46,5,46,6],[46,7,46,8],[47,5,47,6],[47,7,47,8],[48,5,48,6],[48,7,48,8],[49,5,49,6],[49,7,49,8],[50,5,50,6],[50,7,50,8],[51,0,52,0],[51,1,52,8],[53,0,54,0],[53,1,54,8]]}
["双通道定点零售药店药店申请表"]
[{"$nulls":6},"申请日期","    年   月    日"]
["定点零售药店名称（加盖备案公章）             ",{"$nulls":4},"国家编码"]
["统一社会信用代码",{"$nulls":4},"药品经营许可证号"]
["药店地址",{"$nulls":5},"近3年变更情况",null,"有□ 无□"]
["首次签订青岛市定点零售药店协议\n起止日期",{"$nulls":4},"目前有效的青岛市  定点零售药店协议  起止日期"]
["法定代表人姓名及身份证号码",{"$nulls":5},"近3年变更情况",null,"有□ 无□"]
["企业负责人姓名及身份证号码",{"$nulls":5},"近3年变更情况",null,"有□ 无□"]
["联系人",null,null,"联系电话",null,null,"手机"]
["执业药师注册管理信息"]
["姓名","国家平台 \n药师编码","注册证号","资格证号","身份证号码",null,null," 在职/退休","参保单位（在职）"]
[]
[]
[]
[]
["取得国谈药品、耗材经销权情况表"]
[]
["序号","国家目录\n编码","通用名","商品名","规格\n（包装）","生产企业             （与国家医保目录信息一致）",null,"备注"]
[]
["小计"]
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["申 报\n材 料\n初 审\n情 况","\n\n                    \n                      经办人：                            年   月   日      "]
[]
["申 报\n材 料\n审 核\n情 况","\n\n\n                    \n                      审核人：                             年   月   日      "]