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["在肥高校在校大学生转诊转院/异地就医备案单"]
["学校名称（盖章）：                                   备案时间:"]
["姓名",null,"性别",null,"年龄"]
["身份证号码",{"$nulls":3},"学籍号"]
["备案类别\n（□内划√）","□ 转诊转院(在肥首诊后)",null,"□ 异地就医（非在校时间）"]
["就医地"]
["病情摘要及备案情况说明："]
[]
["学校学生辅导员意见："]
["                                   签字："]
["                                                        年 　　 月  　　日"]
["学院（系）意见：",null,null,"学校医保经办机构意见："]
[]
["    （盖章）",{"$nulls":3},"经办人员签字："]
["                年 　　 月  　　日",null,null,"              年 　　 月  　　日"]