上海市養(yǎng)老服務(wù)合同示范文本 (2012機(jī)構(gòu)版)

上海市養(yǎng)老服務(wù)合同示范文本 (2012機(jī)構(gòu)版)

15102016-07-31 19:40  中國政務(wù)服務(wù)網(wǎng)





編號





上海市養(yǎng)老服務(wù)合同



示范文本



2012機(jī)構(gòu)版)










上海市工商行政管理


上海市民政 制定


上海市社會福利行業(yè)協(xié)會



合同編號:



上海市養(yǎng)老服務(wù)合同示范文本


2012機(jī)構(gòu)版)



甲方(服務(wù)機(jī)構(gòu)):


乙方(服務(wù)對象):


丙方(擔(dān) 人):



根據(jù)《中華人民共和國合同法》及其他有關(guān)法律、法規(guī)的規(guī)定,甲、乙、丙三方本著平等、自愿、誠實守信的原則,經(jīng)協(xié)商一致,簽訂本合同。


第一條 服務(wù)內(nèi)容與要求


1.根據(jù)老年照護(hù)等級評估要求確定的乙方照護(hù)等級,甲方為乙方提供約定服務(wù),見《首次服務(wù)項目確認(rèn)表》(附件1)。


2.服務(wù)要求:各方同意養(yǎng)老服務(wù)標(biāo)準(zhǔn)按照以下第 執(zhí)行。


1)《上海市養(yǎng)老機(jī)構(gòu)設(shè)施與服務(wù)要求》。


2)其它:


第二條 服務(wù)期限


1.服務(wù)期限自 日至 日。


第三條 服務(wù)費用


1.乙方支付甲方服務(wù)費用:人民幣 /


其中床位(托管)費:人民幣 / 。


護(hù)理費:人民幣 / 。


2.其它: 。


第四條 支付方式


1.服務(wù)費用支付方式選擇以下第 項執(zhí)行。


1)按月支付(每月 日前支付當(dāng)月費用)。


2)其它


2.結(jié)算方式選擇以下第 項執(zhí)行。


1)現(xiàn)金結(jié)算 2)支票轉(zhuǎn)賬


第五條 保證金


1.乙方支付甲方入院保證金:人民幣 元,合同簽訂之日起 日內(nèi)支付。本合同終止時根據(jù)實際使用情況結(jié)清。


第六條 甲方權(quán)利義務(wù)


1.取得上海市養(yǎng)老機(jī)構(gòu)執(zhí)業(yè)證書和法人資格證書。


2.在乙方入住期間對其身體狀況進(jìn)行持續(xù)評估,如需變更照護(hù)等級的,應(yīng)經(jīng)乙方或丙方同意,并調(diào)整相應(yīng)的服務(wù)內(nèi)容和服務(wù)費用,見《變更事項確認(rèn)表》(1-3)(附件3)。


3.按約定對乙方進(jìn)行照護(hù),如有下列情形之一的,甲方應(yīng)做出相應(yīng)處置:


1)乙方需要外出就醫(yī)的,甲方應(yīng)及時告知丙方,并由丙方攜乙方就診。緊急情況下,可送急診處置,由此產(chǎn)生的費用由乙方承擔(dān)。


2)乙方外出就診后所配藥品,甲方按衛(wèi)生行政部門的相關(guān)規(guī)定及醫(yī)囑執(zhí)行。如乙方為中度、重度照護(hù)者,甲方還應(yīng)提供外配藥品管理服務(wù),并辦理相關(guān)藥物交接手續(xù)。


3)乙方出現(xiàn)下列情況之一的,甲方應(yīng)告知丙方攜乙方外出就醫(yī)。在征得丙方同意后,甲方可采取必要的安全保護(hù)措施。否則,甲方可按本合同第十條執(zhí)行。


a)乙方因機(jī)能進(jìn)行性衰退,坐、立困難,危及自身或他人安全的;


b)乙方因認(rèn)知能力下降,行為不能自主,危及自身或他人安全的;


c)乙方因疾病或其他原因出現(xiàn)精神異常,危及自身或他人安全的。


第七條 乙方權(quán)利義務(wù)


1.如實告知健康狀況和藥品使用情況,并填寫《首次入住健康狀況介紹》(附件2)。


2.配合甲方做好持續(xù)評估,確認(rèn)照護(hù)等級。


3.入住期間配合甲方管理,并遵守下列規(guī)定:


1)貴重物品不宜帶入院內(nèi),如有帶入自行保管。


2)未經(jīng)甲方許可,不得使用自帶家用電器。


3)吸煙者應(yīng)在指定地點吸煙。


4)照護(hù)等級評估為中度、重度的,外出就醫(yī)所配藥品應(yīng)委托甲方管理,并與甲方明確約定(約定內(nèi)容見本合同第十二條)。


5)出院時,應(yīng)及時清理物品,結(jié)清相關(guān)費用。


第八條 丙方權(quán)利義務(wù)


1.有權(quán)了解乙方的生活情況,并可對甲方的照護(hù)工作提出意見和建議。


2.當(dāng)乙方無法履行告知義務(wù)時,應(yīng)向甲方如實告知乙方的健康狀況和用藥情況,并填寫《首次入住健康狀況介紹》(附件2)。


3.對乙方入住期間的費用及造成的經(jīng)濟(jì)損失等承擔(dān)連帶保證責(zé)任。


4.在乙方入住期間配合甲方管理:


1)對甲方反映的有關(guān)乙方事宜,應(yīng)配合甲方共同處理。


2)乙方需外出就醫(yī)的,應(yīng)及時攜乙方到醫(yī)院就診,根據(jù)醫(yī)囑執(zhí)行,并向甲方如實告知乙方的就醫(yī)情況。


3)聯(lián)系方式如有變動,應(yīng)及時以書面方式告知甲方。


4)當(dāng)乙方不能自行處理時,辦理乙方相應(yīng)的費用結(jié)算,物品清理等事宜。


第九條 保險


1.甲、乙、丙三方可協(xié)商一致辦理相關(guān)保險事宜。


2.甲方 (應(yīng)填同意或不同意,打無效)投保養(yǎng)老機(jī)構(gòu)責(zé)任險


3.乙方 (應(yīng)填同意或不同意,打無效)投保入住老人意外險


第十條 合同的解除


1.有下列情形之一的,甲方可書面通知乙方或丙方解除本合同:


1)乙方出現(xiàn)精神障礙,已經(jīng)危及自身或他人人身、財產(chǎn)安全的。


2)乙方患有必須隔離治療的傳染病。


3)逾期 月未支付費用(不得少于2個月)。


4)乙方連續(xù)請假外出超過 天(不得少于30天)。


2.有下列情形之一的,乙方可書面通知甲方解除本合同:


1)甲方喪失養(yǎng)老機(jī)構(gòu)執(zhí)業(yè)資格的。


2)不符合消防安全、衛(wèi)生防疫、食藥監(jiān)等相關(guān)行政主管部門的規(guī)定要求,受到行政處罰的。


3)因甲方原因造成乙方人身傷害的。


第十一條 違約責(zé)任


1.甲方未按合同約定提供服務(wù),給乙方造成損失的,應(yīng)予以賠償。


2乙方逾期支付服務(wù)費用的,每逾期一天應(yīng)按逾期支付部分費用 %向甲方支付違約金。


3.其他違約責(zé)任:


。


第十二條 其他約定


1.外出約定: 。


2.委托發(fā)放外配藥品約定: 。


3.其它約定: 。


第十三條 爭議解決方式


合同各方發(fā)生爭議的,可協(xié)商解決,或向有關(guān)部門申請調(diào)解;也可提請上海仲裁委員會仲裁不愿意仲裁而選擇向法院提起訴訟的,請雙方在簽署合同時將此仲裁條款劃去


第十四條 附則


1.本合同未盡事宜,可另行協(xié)商簽訂補(bǔ)充協(xié)議。


2.本合同附件是本合同的組成部分,具有同等法律效力。


3.本合同自各方簽字或蓋章之日起生效。本合同一式三份,甲、乙、丙三方各執(zhí)一份。



本合同附件:1.《首次服務(wù)項目確認(rèn)表》


2.《首次入住健康狀況介紹


3.《變更事項確認(rèn)表》(1-3



甲方(服務(wù)機(jī)構(gòu)):


名  稱


住所(址) 郵編


法定代表人 聯(lián)系電話


簽字/蓋章



乙方(服務(wù)對象):


姓  名 性 別 出生年月


身份證號


住所(址)


戶籍所在地 郵編


簽字/蓋章



丙方(擔(dān)保人):


姓  名 性 別 出生年月


身份證號


住所地


戶籍所在地 郵編


與乙方關(guān)系 聯(lián)系電話


簽字/蓋章



簽約日期



附件1


首次服務(wù)項目確認(rèn)表



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{placeholder tag=td i=2227} {placeholder tag=p i=508} {placeholder tag=span i=1543}提供{placeholder tag=span i=1544} {placeholder tag=span i=1545}項服務(wù)

{placeholder tag=tr i=2371} {placeholder tag=td i=2228} {placeholder tag=p i=509} {placeholder tag=span i=1546}其它

{placeholder tag=td i=2229} {placeholder tag=p i=510} {placeholder tag=span i=1547}A{placeholder tag=span i=1548}物品清潔、消毒{placeholder tag=span i=1549} {placeholder tag=span i=1550}□{placeholder tag=span i=1551} {placeholder tag=span i=1552} {placeholder tag=span i=1553} B{placeholder tag=span i=1554}預(yù)防保健{placeholder tag=span i=1555} {placeholder tag=span i=1556}□{placeholder tag=span i=1557} C{placeholder tag=span i=1558}社交娛樂{placeholder tag=span i=1559}{placeholder tag=span i=1560}□

{placeholder tag=td i=2230} {placeholder tag=p i=511} {placeholder tag=span i=1561}提供{placeholder tag=span i=1562} {placeholder tag=span i=1563}項服務(wù)

{placeholder tag=tr i=2372} {placeholder tag=td i=2231} {placeholder tag=p i=512} {placeholder tag=span i=1564}約定服務(wù)

{placeholder tag=td i=2232} {placeholder tag=p i=513} {placeholder tag=span i=1565}

{placeholder tag=td i=2233} {placeholder tag=p i=514} {placeholder tag=span i=1566}

{placeholder tag=tr i=2373} {placeholder tag=td i=2234} {placeholder tag=p i=515} {placeholder tag=span i=1567}甲方代表簽字{placeholder tag=span i=1568} {placeholder tag=span i=1569} {placeholder tag=span i=1570}{placeholder tag=span i=1571}甲方蓋章{placeholder tag=span i=1572} {placeholder tag=span i=1573} {placeholder tag=span i=1574}{placeholder tag=span i=1575}乙{placeholder tag=span i=1576}/{placeholder tag=span i=1577}丙方簽字{placeholder tag=span i=1578} {placeholder tag=span i=1579} {placeholder tag=span i=1580} {placeholder tag=span i=1581}

{placeholder tag=p i=516} {placeholder tag=span i=1582} {placeholder tag=span i=1583} {placeholder tag=span i=1584}{placeholder tag=span i=1585}年{placeholder tag=span i=1586} {placeholder tag=span i=1587}月{placeholder tag=span i=1588} {placeholder tag=span i=1589}日{placeholder tag=span i=1590} {placeholder tag=span i=1591} {placeholder tag=span i=1592} {placeholder tag=span i=1593}年{placeholder tag=span i=1594} {placeholder tag=span i=1595}月{placeholder tag=span i=1596} {placeholder tag=span i=1597}日

{placeholder tag=tr i=2374} {placeholder tag=td i=2235} {placeholder tag=p i=517} {placeholder tag=span i=1598}注{placeholder tag=span i=1599}:{placeholder tag=span i=1600}1{placeholder tag=span i=1601}.{placeholder tag=span i=1602}根據(jù)入住老年人的照護(hù)等級確定相應(yīng)服務(wù)內(nèi)容。

{placeholder tag=p i=518} {placeholder tag=span i=1603}2{placeholder tag=span i=1604}.{placeholder tag=span i=1605}“服務(wù)內(nèi)容”一欄在確認(rèn)內(nèi)容后的“□”內(nèi)打勾。

{placeholder tag=p i=519} {placeholder tag=span i=1606}3{placeholder tag=span i=1607}.{placeholder tag=span i=1608}“合計”一欄在“提供{placeholder tag=span i=1609} {placeholder tag=span i=1610}項服務(wù)”內(nèi)填寫字母。

{placeholder tag=tr i=2375} {placeholder tag=td i=2236} {placeholder tag=td i=2237} {placeholder tag=td i=2238} {placeholder tag=td i=2239} {placeholder tag=td i=2240} {placeholder tag=td i=2241}

性別

出生年月

入住區(qū)域

床號

照護(hù)等級 評估日期

服務(wù)項目

服務(wù)內(nèi)容

合計

進(jìn)食

A喂食 B飲水 C食物切碎或攪拌

提供 項服務(wù)

{placeholder tag=p i=473} {placeholder tag=span i=1324}修飾

{placeholder tag=p i=474} {placeholder tag=span i=1325}洗浴

{placeholder tag=p i=520} {placeholder tag=br i=143}

{placeholder tag=p i=521} {placeholder tag=span i=1611}

{placeholder tag=p i=522} {placeholder tag=br i=144}

{placeholder tag=p i=523} {placeholder tag=span i=1612}

{placeholder tag=p i=524} {placeholder tag=br i=145}

{placeholder tag=p i=525} {placeholder tag=span i=1613}附件{placeholder tag=span i=1614}2

{placeholder tag=p i=526} {placeholder tag=br i=146}

{placeholder tag=p i=527} {placeholder tag=span i=1615}首次入住健康狀況介紹

{placeholder tag=p i=528} {placeholder tag=br i=147}

{placeholder tag=p i=529} {placeholder tag=span i=1616}

{placeholder tag=p i=530} {placeholder tag=br i=148}

{placeholder tag=div i=169} {placeholder tag=table i=2174} {placeholder tag=tr i=2376} {placeholder tag=td i=2242} {placeholder tag=p i=531} {placeholder tag=span i=1617}乙方姓名

{placeholder tag=td i=2243} {placeholder tag=p i=532} {placeholder tag=span i=1618}

{placeholder tag=td i=2244} {placeholder tag=p i=533} {placeholder tag=span i=1619}性別

{placeholder tag=td i=2245} {placeholder tag=p i=534} {placeholder tag=span i=1620}

{placeholder tag=td i=2246} {placeholder tag=p i=535} {placeholder tag=span i=1621}出生年月

{placeholder tag=td i=2247} {placeholder tag=p i=536} {placeholder tag=span i=1622}

{placeholder tag=tr i=2377} {placeholder tag=td i=2248} {placeholder tag=p i=537} {placeholder tag=span i=1623}入住部門

{placeholder tag=td i=2249} {placeholder tag=p i=538} {placeholder tag=span i=1624}

{placeholder tag=td i=2250} {placeholder tag=p i=539} {placeholder tag=span i=1625}床號

{placeholder tag=td i=2251} {placeholder tag=p i=540} {placeholder tag=span i=1626}

{placeholder tag=td i=2252} {placeholder tag=p i=541} {placeholder tag=span i=1627}照護(hù)等級{placeholder tag=span i=1628} {placeholder tag=span i=1629}{placeholder tag=span i=1630}評估日期{placeholder tag=span i=1631}

{placeholder tag=tr i=2378} {placeholder tag=td i=2253} {placeholder tag=p i=542} {placeholder tag=span i=1632}丙方姓名

{placeholder tag=td i=2254} {placeholder tag=p i=543} {placeholder tag=span i=1633}

{placeholder tag=td i=2255} {placeholder tag=p i=544} {placeholder tag=span i=1634}與老人關(guān)系

{placeholder tag=td i=2256} {placeholder tag=p i=545} {placeholder tag=span i=1635}

{placeholder tag=tr i=2379} {placeholder tag=td i=2257} {placeholder tag=p i=546} {placeholder tag=span i=1636}既往疾病介紹

{placeholder tag=p i=547} {placeholder tag=span i=1637}□慢性支氣管炎{placeholder tag=span i=1638} {placeholder tag=span i=1639}□肺氣腫{placeholder tag=span i=1640} {placeholder tag=span i=1641}□肺源性心臟病{placeholder tag=span i=1642} {placeholder tag=span i=1643}□支氣管哮喘、擴(kuò)張{placeholder tag=span i=1644} {placeholder tag=span i=1645}□氣胸

{placeholder tag=p i=548} {placeholder tag=span i=1646}□慢性心衰{placeholder tag=span i=1647} {placeholder tag=span i=1648}□心律失常{placeholder tag=span i=1649} {placeholder tag=span i=1650}□高血壓{placeholder tag=span i=1651} {placeholder tag=span i=1652}□冠心病{placeholder tag=span i=1653} {placeholder tag=span i=1654}□心臟瓣膜病

{placeholder tag=p i=549} {placeholder tag=span i=1655}□心肌病{placeholder tag=span i=1656} {placeholder tag=span i=1657}□脈管炎{placeholder tag=span i=1658} {placeholder tag=span i=1659}□肺結(jié)核{placeholder tag=span i=1660} {placeholder tag=span i=1661}□消化道出血{placeholder tag=span i=1662} {placeholder tag=span i=1663}□胃潰瘍

{placeholder tag=p i=550} {placeholder tag=span i=1664}□結(jié)腸炎{placeholder tag=span i=1665} {placeholder tag=span i=1666}□膽囊炎{placeholder tag=span i=1667} {placeholder tag=span i=1668}□膽結(jié)石{placeholder tag=span i=1669} {placeholder tag=span i=1670}□肝炎{placeholder tag=span i=1671} {placeholder tag=span i=1672}□肝硬化

{placeholder tag=p i=551} {placeholder tag=span i=1673}□腎功能不全{placeholder tag=span i=1674} {placeholder tag=span i=1675}□腎炎{placeholder tag=span i=1676} {placeholder tag=span i=1677}□泌尿系結(jié)石{placeholder tag=span i=1678} {placeholder tag=span i=1679}□前列腺炎

{placeholder tag=p i=552} {placeholder tag=span i=1680}□甲狀腺?。卓?、甲減、甲狀腺炎、結(jié)節(jié)){placeholder tag=span i=1681} {placeholder tag=span i=1682}□糖尿病{placeholder tag=span i=1683} {placeholder tag=span i=1684}□骨質(zhì)疏松

{placeholder tag=p i=553} {placeholder tag=span i=1685}□痛風(fēng){placeholder tag=span i=1686} {placeholder tag=span i=1687}□關(guān)節(jié)炎{placeholder tag=span i=1688} {placeholder tag=span i=1689}□紅斑狼瘡{placeholder tag=span i=1690} {placeholder tag=span i=1691}□貧血

{placeholder tag=p i=554} {placeholder tag=span i=1692}□腦出血{placeholder tag=span i=1693} {placeholder tag=span i=1694}□腦梗塞{placeholder tag=span i=1695} {placeholder tag=span i=1696}□帕金森氏綜合癥{placeholder tag=span i=1697} {placeholder tag=span i=1698}□重癥肌無力{placeholder tag=span i=1699} {placeholder tag=span i=1700}□癲癇

{placeholder tag=p i=555} {placeholder tag=span i=1701}□美尼爾氏綜合征{placeholder tag=span i=1702} {placeholder tag=span i=1703}□老年性癡呆{placeholder tag=span i=1704} {placeholder tag=span i=1705}□抑郁癥{placeholder tag=span i=1706} {placeholder tag=span i=1707}□焦慮癥

{placeholder tag=p i=556} {placeholder tag=span i=1708}□腫瘤{placeholder tag=span i=1709} {placeholder tag=span i=1710}□白內(nèi)障{placeholder tag=span i=1711} {placeholder tag=span i=1712}□青光眼{placeholder tag=span i=1713} {placeholder tag=span i=1714}□皮膚病

{placeholder tag=p i=557} {placeholder tag=span i=1715}其它疾病{placeholder tag=span i=1716}

{placeholder tag=tr i=2380} {placeholder tag=td i=2258} {placeholder tag=p i=558} {placeholder tag=span i=1717}現(xiàn)有疾病{placeholder tag=span i=1718}介紹

{placeholder tag=p i=559} {placeholder tag=span i=1719}□慢性支氣管炎{placeholder tag=span i=1720} {placeholder tag=span i=1721}□肺氣腫{placeholder tag=span i=1722} {placeholder tag=span i=1723}□肺源性心臟病{placeholder tag=span i=1724} {placeholder tag=span i=1725}□支氣管哮喘、擴(kuò)張{placeholder tag=span i=1726} {placeholder tag=span i=1727}□氣胸

{placeholder tag=p i=560} {placeholder tag=span i=1728}□慢性心衰{placeholder tag=span i=1729} {placeholder tag=span i=1730}□心律失常{placeholder tag=span i=1731} {placeholder tag=span i=1732}□高血壓{placeholder tag=span i=1733} {placeholder tag=span i=1734}□冠心病

{placeholder tag=p i=561} {placeholder tag=span i=1735}□心臟瓣膜病{placeholder tag=span i=1736} {placeholder tag=span i=1737}□心肌病{placeholder tag=span i=1738} {placeholder tag=span i=1739}□脈管炎

{placeholder tag=p i=562} {placeholder tag=span i=1740}□消化道出血{placeholder tag=span i=1741} {placeholder tag=span i=1742}□胃潰瘍{placeholder tag=span i=1743} {placeholder tag=span i=1744}□結(jié)腸炎{placeholder tag=span i=1745} {placeholder tag=span i=1746}□膽囊炎{placeholder tag=span i=1747} {placeholder tag=span i=1748}□膽結(jié)石{placeholder tag=span i=1749} {placeholder tag=span i=1750}□肝硬化

{placeholder tag=p i=563} {placeholder tag=span i=1751}□腎功能不全{placeholder tag=span i=1752} {placeholder tag=span i=1753}□腎炎{placeholder tag=span i=1754} {placeholder tag=span i=1755}□泌尿系結(jié)石{placeholder tag=span i=1756} {placeholder tag=span i=1757}□前列腺炎

{placeholder tag=p i=564} {placeholder tag=span i=1758}□甲狀腺?。卓骸⒓诇p、甲狀腺炎、結(jié)節(jié)){placeholder tag=span i=1759} {placeholder tag=span i=1760}□糖尿病{placeholder tag=span i=1761} {placeholder tag=span i=1762}□骨質(zhì)疏松

{placeholder tag=p i=565} {placeholder tag=span i=1763}□痛風(fēng){placeholder tag=span i=1764} {placeholder tag=span i=1765}□關(guān)節(jié)炎{placeholder tag=span i=1766} {placeholder tag=span i=1767}□紅斑狼瘡{placeholder tag=span i=1768} {placeholder tag=span i=1769}□貧血

{placeholder tag=p i=566} {placeholder tag=span i=1770}□腦出血{placeholder tag=span i=1771} {placeholder tag=span i=1772}□腦梗塞{placeholder tag=span i=1773} {placeholder tag=span i=1774}□帕金森氏綜合癥{placeholder tag=span i=1775} {placeholder tag=span i=1776}□重癥肌無力{placeholder tag=span i=1777} {placeholder tag=span i=1778}□癲癇

{placeholder tag=p i=567} {placeholder tag=span i=1779}□美尼爾氏綜合征{placeholder tag=span i=1780} {placeholder tag=span i=1781}□老年性癡呆{placeholder tag=span i=1782} {placeholder tag=span i=1783}□抑郁癥{placeholder tag=span i=1784} {placeholder tag=span i=1785}□焦慮癥

{placeholder tag=p i=568} {placeholder tag=span i=1786}□腫瘤{placeholder tag=span i=1787} {placeholder tag=span i=1788}□白內(nèi)障{placeholder tag=span i=1789} {placeholder tag=span i=1790}□青光眼{placeholder tag=span i=1791} {placeholder tag=span i=1792}□皮膚病

{placeholder tag=p i=569} {placeholder tag=span i=1793}其它疾病{placeholder tag=span i=1794}

{placeholder tag=tr i=2381} {placeholder tag=td i=2259} {placeholder tag=p i=570} {placeholder tag=span i=1795}現(xiàn)服藥情況

{placeholder tag=p i=571} {placeholder tag=span i=1796}

{placeholder tag=tr i=2382} {placeholder tag=td i=2260} {placeholder tag=p i=572} {placeholder tag=span i=1797}注:{placeholder tag=span i=1798}1{placeholder tag=span i=1799}.{placeholder tag=span i=1800}乙方申請入住甲方時,由乙方或丙方填寫,介紹乙方所患疾病情況。

{placeholder tag=p i=573} {placeholder tag=span i=1801}2{placeholder tag=span i=1802}.{placeholder tag=span i=1803}在“□”內(nèi)用“√”表示確認(rèn)患有的疾病。

{placeholder tag=tr i=2383} {placeholder tag=td i=2261} {placeholder tag=td i=2262} {placeholder tag=td i=2263} {placeholder tag=td i=2264} {placeholder tag=td i=2265} {placeholder tag=td i=2266}
{placeholder tag=p i=574} {placeholder tag=br i=149}

{placeholder tag=p i=575} {placeholder tag=span i=1804}

{placeholder tag=p i=576} {placeholder tag=br i=150}

{placeholder tag=p i=577} {placeholder tag=span i=1805}附件{placeholder tag=span i=1806}3{placeholder tag=span i=1807} 變更事項確認(rèn)表({placeholder tag=span i=1808}1{placeholder tag=span i=1809}-{placeholder tag=span i=1810}3{placeholder tag=span i=1811})

{placeholder tag=p i=578} {placeholder tag=br i=151}

{placeholder tag=p i=579} {placeholder tag=span i=1812}

{placeholder tag=p i=580} {placeholder tag=br i=152}

{placeholder tag=p i=581} {placeholder tag=span i=1813}變更事項確認(rèn)表({placeholder tag=span i=1814}1{placeholder tag=span i=1815})

{placeholder tag=p i=582} {placeholder tag=br i=153}

{placeholder tag=p i=583} {placeholder tag=span i=1816}

{placeholder tag=p i=584} {placeholder tag=br i=154}

{placeholder tag=div i=170} {placeholder tag=table i=2175} {placeholder tag=tr i=2384} {placeholder tag=td i=2267} {placeholder tag=p i=585} {placeholder tag=span i=1817}姓{placeholder tag=span i=1818} {placeholder tag=span i=1819}名

{placeholder tag=td i=2268} {placeholder tag=p i=586} {placeholder tag=span i=1820}

{placeholder tag=td i=2269} {placeholder tag=p i=587} {placeholder tag=span i=1821}性別

{placeholder tag=td i=2270} {placeholder tag=p i=588} {placeholder tag=span i=1822}

{placeholder tag=td i=2271} {placeholder tag=p i=589} {placeholder tag=span i=1823}出生年月

{placeholder tag=td i=2272} {placeholder tag=p i=590} {placeholder tag=span i=1824}

{placeholder tag=tr i=2385} {placeholder tag=td i=2273} {placeholder tag=p i=591} {placeholder tag=span i=1825}入住區(qū)域

{placeholder tag=td i=2274} {placeholder tag=p i=592} {placeholder tag=span i=1826}

{placeholder tag=td i=2275} {placeholder tag=p i=593} {placeholder tag=span i=1827}床號

{placeholder tag=td i=2276} {placeholder tag=p i=594} {placeholder tag=span i=1828}

{placeholder tag=td i=2277} {placeholder tag=p i=595} {placeholder tag=span i=1829}照護(hù)等級(首次){placeholder tag=span i=1830} {placeholder tag=span i=1831}{placeholder tag=span i=1832}評估日期{placeholder tag=span i=1833} {placeholder tag=span i=1834} {placeholder tag=span i=1835}

{placeholder tag=tr i=2386} {placeholder tag=td i=2278} {placeholder tag=p i=596} {placeholder tag=span i=1836}變更事項

{placeholder tag=td i=2279} {placeholder tag=p i=597} {placeholder tag=span i=1837}變更后的狀況

{placeholder tag=td i=2280} {placeholder tag=p i=598} {placeholder tag=span i=1838}變更后簽章

{placeholder tag=tr i=2387} {placeholder tag=td i=2281} {placeholder tag=p i=599} {placeholder tag=span i=1839}照護(hù)

{placeholder tag=p i=600} {placeholder tag=span i=1840}等級

{placeholder tag=td i=2282} {placeholder tag=p i=601} {placeholder tag=span i=1841}第一次變更

{placeholder tag=p i=602} {placeholder tag=span i=1842}

{placeholder tag=p i=603} {placeholder tag=span i=1843}

{placeholder tag=p i=604} {placeholder tag=span i=1844}照護(hù)等級{placeholder tag=span i=1845} {placeholder tag=span i=1846}

{placeholder tag=td i=2283} {placeholder tag=p i=605} {placeholder tag=span i=1847}甲方代表簽章:

{placeholder tag=p i=606} {placeholder tag=span i=1848}

{placeholder tag=p i=607} {placeholder tag=span i=1849}

{placeholder tag=p i=608} {placeholder tag=span i=1850}乙{placeholder tag=span i=1851}/{placeholder tag=span i=1852}丙方簽章{placeholder tag=span i=1853}:

{placeholder tag=p i=609} {placeholder tag=span i=1854} {placeholder tag=span i=1855}年{placeholder tag=span i=1856} {placeholder tag=span i=1857}月{placeholder tag=span i=1858} {placeholder tag=span i=1859}日

{placeholder tag=tr i=2388} {placeholder tag=td i=2284} {placeholder tag=p i=610} {placeholder tag=span i=1860}第二次變更

{placeholder tag=p i=611} {placeholder tag=span i=1861}

{placeholder tag=p i=612} {placeholder tag=span i=1862}

{placeholder tag=p i=613} {placeholder tag=span i=1863}照護(hù)等級{placeholder tag=span i=1864} {placeholder tag=span i=1865}

{placeholder tag=p i=614} {placeholder tag=span i=1866}

{placeholder tag=td i=2285} {placeholder tag=p i=615} {placeholder tag=span i=1867}甲方代表簽章:

{placeholder tag=p i=616} {placeholder tag=span i=1868}

{placeholder tag=p i=617} {placeholder tag=span i=1869}

{placeholder tag=p i=618} {placeholder tag=span i=1870}乙{placeholder tag=span i=1871}/{placeholder tag=span i=1872}丙方簽章{placeholder tag=span i=1873}:

{placeholder tag=p i=619} {placeholder tag=span i=1874}

{placeholder tag=p i=620} {placeholder tag=span i=1875} {placeholder tag=span i=1876}年{placeholder tag=span i=1877} {placeholder tag=span i=1878}月{placeholder tag=span i=1879} {placeholder tag=span i=1880}日

{placeholder tag=tr i=2389} {placeholder tag=td i=2286} {placeholder tag=p i=621} {placeholder tag=span i=1881}付費

{placeholder tag=p i=622} {placeholder tag=span i=1882}標(biāo)準(zhǔn)

{placeholder tag=td i=2287} {placeholder tag=p i=623} {placeholder tag=span i=1883}第一次變更

{placeholder tag=p i=624} {placeholder tag=span i=1884}

{placeholder tag=p i=625} {placeholder tag=span i=1885}床位(托管)費:人民幣{placeholder tag=span i=1886} {placeholder tag=span i=1887}元{placeholder tag=span i=1888}/{placeholder tag=span i=1889}月

{placeholder tag=p i=626} {placeholder tag=span i=1890}

{placeholder tag=p i=627} {placeholder tag=span i=1891}護(hù)理費:人民幣{placeholder tag=span i=1892} {placeholder tag=span i=1893} {placeholder tag=span i=1894}元{placeholder tag=span i=1895}/{placeholder tag=span i=1896}月

{placeholder tag=td i=2288} {placeholder tag=p i=628} {placeholder tag=span i=1897}甲方代表簽章:

{placeholder tag=p i=629} {placeholder tag=span i=1898}

{placeholder tag=p i=630} {placeholder tag=span i=1899}乙{placeholder tag=span i=1900}/{placeholder tag=span i=1901}丙方簽章{placeholder tag=span i=1902}:

{placeholder tag=p i=631} {placeholder tag=span i=1903}

{placeholder tag=p i=632} {placeholder tag=span i=1904} {placeholder tag=span i=1905}年{placeholder tag=span i=1906} {placeholder tag=span i=1907}月{placeholder tag=span i=1908} {placeholder tag=span i=1909}日

{placeholder tag=tr i=2390} {placeholder tag=td i=2289} {placeholder tag=p i=633} {placeholder tag=span i=1910}第二次變更

{placeholder tag=p i=634} {placeholder tag=span i=1911}

{placeholder tag=p i=635} {placeholder tag=span i=1912}床位(托管)費:人民幣{placeholder tag=span i=1913} {placeholder tag=span i=1914}元{placeholder tag=span i=1915}/{placeholder tag=span i=1916}月

{placeholder tag=p i=636} {placeholder tag=span i=1917}

{placeholder tag=p i=637} {placeholder tag=span i=1918}護(hù)理費:人民幣{placeholder tag=span i=1919} {placeholder tag=span i=1920}元{placeholder tag=span i=1921}/{placeholder tag=span i=1922}月

{placeholder tag=td i=2290} {placeholder tag=p i=638} {placeholder tag=span i=1923}甲方代表簽章:

{placeholder tag=p i=639} {placeholder tag=span i=1924}

{placeholder tag=p i=640} {placeholder tag=span i=1925}乙{placeholder tag=span i=1926}/{placeholder tag=span i=1927}丙方簽章{placeholder tag=span i=1928}:

{placeholder tag=p i=641} {placeholder tag=span i=1929}

{placeholder tag=p i=642} {placeholder tag=span i=1930} {placeholder tag=span i=1931}年{placeholder tag=span i=1932} {placeholder tag=span i=1933}月{placeholder tag=span i=1934} {placeholder tag=span i=1935}日

{placeholder tag=tr i=2391} {placeholder tag=td i=2291} {placeholder tag=td i=2292} {placeholder tag=td i=2293} {placeholder tag=td i=2294} {placeholder tag=td i=2295} {placeholder tag=td i=2296}
{placeholder tag=p i=643} {placeholder tag=br i=155}

{placeholder tag=p i=644} {placeholder tag=span i=1936}

{placeholder tag=p i=645} {placeholder tag=br i=156}

{placeholder tag=p i=646} {placeholder tag=span i=1937}變更事項確認(rèn)表({placeholder tag=span i=1938}2{placeholder tag=span i=1939})

{placeholder tag=p i=647} {placeholder tag=br i=157}

{placeholder tag=p i=648} {placeholder tag=span i=1940}

{placeholder tag=p i=649} {placeholder tag=br i=158}

{placeholder tag=div i=171} {placeholder tag=table i=2176} {placeholder tag=tr i=2392} {placeholder tag=td i=2297} {placeholder tag=p i=650} {placeholder tag=span i=1941}姓{placeholder tag=span i=1942} {placeholder tag=span i=1943}名

{placeholder tag=td i=2298} {placeholder tag=p i=651} {placeholder tag=span i=1944}

{placeholder tag=td i=2299} {placeholder tag=p i=652} {placeholder tag=span i=1945}性別

{placeholder tag=td i=2300} {placeholder tag=p i=653} {placeholder tag=span i=1946}

{placeholder tag=td i=2301} {placeholder tag=p i=654} {placeholder tag=span i=1947}出生年月

{placeholder tag=td i=2302} {placeholder tag=p i=655} {placeholder tag=span i=1948}

{placeholder tag=tr i=2393} {placeholder tag=td i=2303} {placeholder tag=p i=656} {placeholder tag=span i=1949}入住區(qū)域

{placeholder tag=td i=2304} {placeholder tag=p i=657} {placeholder tag=span i=1950}

{placeholder tag=td i=2305} {placeholder tag=p i=658} {placeholder tag=span i=1951}床號

{placeholder tag=td i=2306} {placeholder tag=p i=659} {placeholder tag=span i=1952}

{placeholder tag=td i=2307} {placeholder tag=p i=660} {placeholder tag=span i=1953}照護(hù)等級(首次){placeholder tag=span i=1954} {placeholder tag=span i=1955}{placeholder tag=span i=1956}評估日期{placeholder tag=span i=1957} {placeholder tag=span i=1958} {placeholder tag=span i=1959}

{placeholder tag=tr i=2394} {placeholder tag=td i=2308} {placeholder tag=p i=661} {placeholder tag=span i=1960}變更事項

{placeholder tag=td i=2309} {placeholder tag=p i=662} {placeholder tag=span i=1961}變更后的狀況

{placeholder tag=td i=2310} {placeholder tag=p i=663} {placeholder tag=span i=1962}變更后簽章

{placeholder tag=tr i=2395} {placeholder tag=td i=2311} {placeholder tag=p i=664} {placeholder tag=span i=1963}照護(hù)

{placeholder tag=p i=665} {placeholder tag=span i=1964}內(nèi)容

{placeholder tag=td i=2312} {placeholder tag=p i=666} {placeholder tag=span i=1965}第一次變更

{placeholder tag=p i=667} {placeholder tag=span i=1966}增加服務(wù)內(nèi)容

{placeholder tag=p i=668} {placeholder tag=span i=1967}

{placeholder tag=p i=669} {placeholder tag=span i=1968}

{placeholder tag=p i=670} {placeholder tag=span i=1969}

{placeholder tag=p i=671} {placeholder tag=span i=1970}

{placeholder tag=p i=672} {placeholder tag=span i=1971}減少服務(wù)內(nèi)容

{placeholder tag=p i=673} {placeholder tag=span i=1972}

{placeholder tag=p i=674} {placeholder tag=span i=1973}

{placeholder tag=p i=675} {placeholder tag=span i=1974}

{placeholder tag=p i=676} {placeholder tag=span i=1975}

{placeholder tag=td i=2313} {placeholder tag=p i=677} {placeholder tag=span i=1976}

{placeholder tag=p i=678} {placeholder tag=span i=1977}

{placeholder tag=p i=679} {placeholder tag=span i=1978}甲方代表簽章:

{placeholder tag=p i=680} {placeholder tag=span i=1979}

{placeholder tag=p i=681} {placeholder tag=span i=1980}

{placeholder tag=p i=682} {placeholder tag=span i=1981}乙{placeholder tag=span i=1982}/{placeholder tag=span i=1983}丙方簽章{placeholder tag=span i=1984}:

{placeholder tag=p i=683} {placeholder tag=span i=1985}

{placeholder tag=p i=684} {placeholder tag=span i=1986}

{placeholder tag=p i=685} {placeholder tag=span i=1987} {placeholder tag=span i=1988}年{placeholder tag=span i=1989} {placeholder tag=span i=1990}月{placeholder tag=span i=1991} {placeholder tag=span i=1992}日

{placeholder tag=p i=686} {placeholder tag=span i=1993}

{placeholder tag=tr i=2396} {placeholder tag=td i=2314} {placeholder tag=p i=687} {placeholder tag=span i=1994}第二次變更

{placeholder tag=p i=688} {placeholder tag=span i=1995}增加服務(wù)內(nèi)容

{placeholder tag=p i=689} {placeholder tag=span i=1996}

{placeholder tag=p i=690} {placeholder tag=span i=1997}

{placeholder tag=p i=691} {placeholder tag=span i=1998}

{placeholder tag=p i=692} {placeholder tag=span i=1999}

{placeholder tag=p i=693} {placeholder tag=span i=2000}減少服務(wù)內(nèi)容

{placeholder tag=p i=694} {placeholder tag=span i=2001}

{placeholder tag=p i=695} {placeholder tag=span i=2002}

{placeholder tag=p i=696} {placeholder tag=span i=2003}

{placeholder tag=p i=697} {placeholder tag=span i=2004}

{placeholder tag=td i=2315} {placeholder tag=p i=698} {placeholder tag=span i=2005}

{placeholder tag=p i=699} {placeholder tag=span i=2006}

{placeholder tag=p i=700} {placeholder tag=span i=2007}甲方代表簽章:

{placeholder tag=p i=701} {placeholder tag=span i=2008}

{placeholder tag=p i=702} {placeholder tag=span i=2009}

{placeholder tag=p i=703} {placeholder tag=span i=2010}乙{placeholder tag=span i=2011}/{placeholder tag=span i=2012}丙方簽章{placeholder tag=span i=2013}:

{placeholder tag=p i=704} {placeholder tag=span i=2014}

{placeholder tag=p i=705} {placeholder tag=span i=2015}

{placeholder tag=p i=706} {placeholder tag=span i=2016} {placeholder tag=span i=2017}年{placeholder tag=span i=2018} {placeholder tag=span i=2019}月{placeholder tag=span i=2020} {placeholder tag=span i=2021}日

{placeholder tag=tr i=2397} {placeholder tag=td i=2316} {placeholder tag=td i=2317} {placeholder tag=td i=2318} {placeholder tag=td i=2319} {placeholder tag=td i=2320} {placeholder tag=td i=2321} {placeholder tag=p i=707} {placeholder tag=br i=159}

{placeholder tag=p i=708} {placeholder tag=span i=2022}

{placeholder tag=p i=709} {placeholder tag=br i=160}

{placeholder tag=p i=710} {placeholder tag=span i=2023}變更事項確認(rèn)表({placeholder tag=span i=2024}3{placeholder tag=span i=2025})

{placeholder tag=p i=711} {placeholder tag=br i=161}

{placeholder tag=p i=712} {placeholder tag=span i=2026}

{placeholder tag=p i=713} {placeholder tag=br i=162}

{placeholder tag=div i=172} {placeholder tag=table i=2177} {placeholder tag=tr i=2398} {placeholder tag=td i=2322} {placeholder tag=p i=714} {placeholder tag=span i=2027}姓{placeholder tag=span i=2028} {placeholder tag=span i=2029}名

{placeholder tag=td i=2323} {placeholder tag=p i=715} {placeholder tag=span i=2030}

{placeholder tag=td i=2324} {placeholder tag=p i=716} {placeholder tag=span i=2031}性別

{placeholder tag=td i=2325} {placeholder tag=p i=717} {placeholder tag=span i=2032}

{placeholder tag=td i=2326} {placeholder tag=p i=718} {placeholder tag=span i=2033}出生年月

{placeholder tag=td i=2327} {placeholder tag=p i=719} {placeholder tag=span i=2034}

{placeholder tag=tr i=2399} {placeholder tag=td i=2328} {placeholder tag=p i=720} {placeholder tag=span i=2035}入住區(qū)域

{placeholder tag=td i=2329} {placeholder tag=p i=721} {placeholder tag=span i=2036}

{placeholder tag=td i=2330} {placeholder tag=p i=722} {placeholder tag=span i=2037}床號

{placeholder tag=td i=2331} {placeholder tag=p i=723} {placeholder tag=span i=2038}

{placeholder tag=td i=2332} {placeholder tag=p i=724} {placeholder tag=span i=2039}照護(hù)等級(首次){placeholder tag=span i=2040} {placeholder tag=span i=2041}{placeholder tag=span i=2042}評估日期{placeholder tag=span i=2043} {placeholder tag=span i=2044} {placeholder tag=span i=2045}

{placeholder tag=tr i=2400} {placeholder tag=td i=2333} {placeholder tag=p i=725} {placeholder tag=span i=2046}變更事項

{placeholder tag=td i=2334} {placeholder tag=p i=726} {placeholder tag=span i=2047}變更后的狀況

{placeholder tag=td i=2335} {placeholder tag=p i=727} {placeholder tag=span i=2048}變更后簽章

{placeholder tag=tr i=2401} {placeholder tag=td i=2336} {placeholder tag=p i=728} {placeholder tag=span i=2049}外出

{placeholder tag=p i=729} {placeholder tag=span i=2050}約定

{placeholder tag=td i=2337} {placeholder tag=p i=730} {placeholder tag=span i=2051}第一次變更:

{placeholder tag=p i=731} {placeholder tag=span i=2052}1{placeholder tag=span i=2053}.{placeholder tag=span i=2054}乙方{placeholder tag=span i=2055}

{placeholder tag=p i=732} {placeholder tag=span i=2056}(應(yīng)填寫能或不能)自主決定外出。

{placeholder tag=p i=733} {placeholder tag=span i=2057}2{placeholder tag=span i=2058}.{placeholder tag=span i=2059}能自主外出的,安全由乙{placeholder tag=span i=2060}/{placeholder tag=span i=2061}丙方自行承擔(dān)。

{placeholder tag=p i=734} {placeholder tag=span i=2062}

{placeholder tag=p i=735} {placeholder tag=span i=2063}注:外出時請帶好個人信息卡。

{placeholder tag=td i=2338} {placeholder tag=p i=736} {placeholder tag=span i=2064}

{placeholder tag=p i=737} {placeholder tag=span i=2065}甲方代表簽章:

{placeholder tag=p i=738} {placeholder tag=span i=2066}

{placeholder tag=p i=739} {placeholder tag=span i=2067}

{placeholder tag=p i=740} {placeholder tag=span i=2068}乙{placeholder tag=span i=2069}/{placeholder tag=span i=2070}丙方簽章{placeholder tag=span i=2071}:

{placeholder tag=p i=741} {placeholder tag=span i=2072}

{placeholder tag=p i=742} {placeholder tag=span i=2073}

{placeholder tag=p i=743} {placeholder tag=span i=2074} {placeholder tag=span i=2075}年{placeholder tag=span i=2076} {placeholder tag=span i=2077}月{placeholder tag=span i=2078} {placeholder tag=span i=2079}日

{placeholder tag=tr i=2402} {placeholder tag=td i=2339} {placeholder tag=p i=744} {placeholder tag=span i=2080}第二次變更:

{placeholder tag=p i=745} {placeholder tag=span i=2081}1{placeholder tag=span i=2082}.{placeholder tag=span i=2083}乙方{placeholder tag=span i=2084}

{placeholder tag=p i=746} {placeholder tag=span i=2085}(應(yīng)填寫能或不能)自主決定外出。

{placeholder tag=p i=747} {placeholder tag=span i=2086}2{placeholder tag=span i=2087}.{placeholder tag=span i=2088}能自主外出的,安全由乙{placeholder tag=span i=2089}/{placeholder tag=span i=2090}丙方自行承擔(dān)。

{placeholder tag=p i=748} {placeholder tag=span i=2091}

{placeholder tag=p i=749} {placeholder tag=span i=2092}注:外出時請帶好個人信息卡。

{placeholder tag=td i=2340} {placeholder tag=p i=750} {placeholder tag=span i=2093}

{placeholder tag=p i=751} {placeholder tag=span i=2094}甲方代表簽章:

{placeholder tag=p i=752} {placeholder tag=span i=2095}

{placeholder tag=p i=753} {placeholder tag=span i=2096}

{placeholder tag=p i=754} {placeholder tag=span i=2097}乙{placeholder tag=span i=2098}/{placeholder tag=span i=2099}丙方簽章{placeholder tag=span i=2100}:

{placeholder tag=p i=755} {placeholder tag=span i=2101}

{placeholder tag=p i=756} {placeholder tag=span i=2102}

{placeholder tag=p i=757} {placeholder tag=span i=2103} {placeholder tag=span i=2104}年{placeholder tag=span i=2105} {placeholder tag=span i=2106}月{placeholder tag=span i=2107} {placeholder tag=span i=2108}日

{placeholder tag=tr i=2403} {placeholder tag=td i=2341} {placeholder tag=p i=758} {placeholder tag=span i=2109}委托

{placeholder tag=p i=759} {placeholder tag=span i=2110}發(fā)放

{placeholder tag=p i=760} {placeholder tag=span i=2111}外配

{placeholder tag=p i=761} {placeholder tag=span i=2112}藥品

{placeholder tag=p i=762} {placeholder tag=span i=2113}約定

{placeholder tag=td i=2342} {placeholder tag=p i=763} {placeholder tag=span i=2114}第一次變更

{placeholder tag=p i=764} {placeholder tag=span i=2115}1{placeholder tag=span i=2116}.{placeholder tag=span i=2117}乙方外出就醫(yī)所配藥品{placeholder tag=span i=2118}

{placeholder tag=p i=765} {placeholder tag=span i=2119}(應(yīng)填寫委托或不委托)甲方按醫(yī)囑發(fā)放。

{placeholder tag=p i=766} {placeholder tag=span i=2120}2{placeholder tag=span i=2121}.{placeholder tag=span i=2122}甲方{placeholder tag=span i=2123} {placeholder tag=span i=2124}(應(yīng)填寫接受或不接受)乙{placeholder tag=span i=2125}/{placeholder tag=span i=2126}丙方委托:外出就醫(yī)所配藥品按醫(yī)囑發(fā)放{placeholder tag=span i=2127}。

{placeholder tag=td i=2343} {placeholder tag=p i=767} {placeholder tag=span i=2128}

{placeholder tag=p i=768} {placeholder tag=span i=2129}甲方代表簽章:

{placeholder tag=p i=769} {placeholder tag=span i=2130}

{placeholder tag=p i=770} {placeholder tag=span i=2131}

{placeholder tag=p i=771} {placeholder tag=span i=2132}乙{placeholder tag=span i=2133}/{placeholder tag=span i=2134}丙方簽章{placeholder tag=span i=2135}:

{placeholder tag=p i=772} {placeholder tag=span i=2136}

{placeholder tag=p i=773} {placeholder tag=span i=2137} {placeholder tag=span i=2138}年{placeholder tag=span i=2139} {placeholder tag=span i=2140}月{placeholder tag=span i=2141} {placeholder tag=span i=2142}日

{placeholder tag=tr i=2404} {placeholder tag=td i=2344} {placeholder tag=p i=774} {placeholder tag=span i=2143}第二次變更

{placeholder tag=p i=775} {placeholder tag=span i=2144}1{placeholder tag=span i=2145}.{placeholder tag=span i=2146}乙方外出就醫(yī)所配藥品{placeholder tag=span i=2147}

{placeholder tag=p i=776} {placeholder tag=span i=2148}(應(yīng)填寫委托或不委托)甲方按醫(yī)囑發(fā)放。

{placeholder tag=p i=777} {placeholder tag=span i=2149}2{placeholder tag=span i=2150}.{placeholder tag=span i=2151}甲方{placeholder tag=span i=2152} {placeholder tag=span i=2153}(應(yīng)填寫接受或不接受)乙{placeholder tag=span i=2154}/{placeholder tag=span i=2155}丙方委托:外出就醫(yī)所配藥品按醫(yī)囑發(fā)放{placeholder tag=span i=2156}。

{placeholder tag=td i=2345} {placeholder tag=p i=778} {placeholder tag=span i=2157}

{placeholder tag=p i=779} {placeholder tag=span i=2158}甲方代表簽章:

{placeholder tag=p i=780} {placeholder tag=span i=2159}

{placeholder tag=p i=781} {placeholder tag=span i=2160}

{placeholder tag=p i=782} {placeholder tag=span i=2161}乙{placeholder tag=span i=2162}/{placeholder tag=span i=2163}丙方簽章{placeholder tag=span i=2164}:

{placeholder tag=p i=783} {placeholder tag=span i=2165}

{placeholder tag=p i=784} {placeholder tag=span i=2166} {placeholder tag=span i=2167}年{placeholder tag=span i=2168} {placeholder tag=span i=2169}月{placeholder tag=span i=2170} {placeholder tag=span i=2171}日

{placeholder tag=tr i=2405} {placeholder tag=td i=2346} {placeholder tag=td i=2347} {placeholder tag=td i=2348} {placeholder tag=td i=2349} {placeholder tag=td i=2350} {placeholder tag=td i=2351} {placeholder tag=p i=785} {placeholder tag=br i=163}

{placeholder tag=p i=786} {placeholder tag=span i=2172}

{placeholder tag=p i=787} {placeholder tag=br i=164}

{placeholder tag=p i=788} {placeholder tag=br i=165}

{placeholder tag=p i=789} {placeholder tag=br i=166}

{placeholder tag=p i=790} {placeholder tag=br i=167}

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