新型农村合作医疗定点医疗机构申请表

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1、附件1：新型农村合作医疗定点医疗机构申请表医疗机构全称 所有制形式 医院等级（一、二、三级）医院类别（综合，专科）法人代表姓名法人代表联系电话详细地址 邮编内设新农合办公室联系人 联系电话（办公室电话及手机）传真电话电子邮箱卫生行政主管部门 执业许可证编号（附复印件）上年度（年）业务收入总数（万元）theprovisionsofelectricpowerconstructionengineeringqualitysupervisionandquality...2.4.1.1theunitworksacc

2、eptancerateof100%,thequalityevaluationofatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulic职工总人数其中：卫生技术人员数主任医师数副主任医师数主治医师数医师数医士数编制床位数实际开放床位数限额或定额付费单病种数限额或定额付费单病种名

3、称申请理由申请医疗机构盖章年月日现场评估意见评估组组长签字年月日审批机关意见 审批机关盖章年月日theprovisionsofelectricpowerconstructionengineeringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequalityevaluationofatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100

4、%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulictheprovisionsofelectricpowerconstructionengineeringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequalityevaluationofatotalscoreof95orabove;2.4.1.

5、2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulic