5
05
11110109000073357M
北京市门头沟区人民政府大台街道办事处
因病致贫家庭医疗救助
11110109000073357M511054100300201
11110109000073357M5110541003002
0
20828ec5-ef4d-4c8a-854e-b6cc40764769
7d4d7252-28f7-4e48-a2d9-f6ff38b70798
3^5
05
门头沟区大台街道
110109004000
北京市门头沟区人民政府大台街道办事处
门头沟区大台街道政务服务中心:工作日9:00-17:00(法定节假日除外)(延时服务时间：工作日上午8:30-9:00，下午17:00-17:30，每周六9:00-15:00，需预约)
门头沟区大台街道政务服务中心:北京市门头沟区大台路8号综合窗口
申请家庭应当填写《申请因病致贫家庭医疗救助经济状况和医疗费用支出情况登记表、声明书、授权书》，如实申报家庭经济状况，授权医保部门对其家庭收入、家庭财产和医疗费用支出情况进行核查。同时提交上一自然年度家庭成员的以下相关材料：
1.户口簿及身份证复印件；
2.《申请因病致贫家庭医疗救助经济状况和医疗费用支出情况登记表、声明书、授权书》；
3.年度收入情况说明及相关财产说明；
4.参加商业保险的，需要提供商业保险主管部门出具的费用结算分割单；
5.对于参加外埠基本医疗保险及参加本市基本医疗保险因特殊原因未能实时结算的本市户籍人员，仍需提交相关医疗费用票据；
6.医保部门认为需要提供的其他证明材料。
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