"居民身份参加基本医疗保险户口资料变更申请表"

"所属镇街:",,"祖庙街道",,,,"所属村居:",,"红棉居委""户口编号:",,"001234",,,,"户口地址:",,"禅城区丝绸大街XX号XXX房""户主姓名:",,"李大",,,,"户主身份证号:",,"4406011966*"变更项目","参保人姓名","身份证号码",,,"性别","与户主关系",,"增减员原因",,"第一联社保经办机构存(印第一联)","第二联参保人存(印第二联)""增加家庭成员","李三","4406021992*男","儿子",,"从**市新迁入户",,,"减少家庭成员","李父","4406011945*男","父亲",,"迁出",,,"以下为变更扣费账户资料及参保人联系电话(手机号码)(注:请在参保人姓名、身份证号码中填写需要办理资料变更的参保人资料)"变更项目","参保人姓名","身份证号码",,"手机号码",,"缴费银行","缴费账户户名","缴费账号","金融或医保账户",,"变更内容","李四","4406021996*135*农业银行","李四","4406021992*金融账户",,"以下为变更家庭联系手机号码""家庭联系电话(手机号码)",,,"135*"注意事项:1.
由于扣费账户开户人迁出或死亡需要修改户口信息的,请同时提供新的扣费账户资料,没有及时提供新的扣费账户资料所造成的损失(使用原账户扣费失败或使用原账户成功扣费等)由申请人承担.
2.
使用社保卡缴费的,需选择在金融账户或医保账户扣费(因参保人无法自行存钱入医保账户,请谨慎选择)"参保人或家庭代办人签名:李大联系电话:135********日期:2018年**月**日""受理人:初核人:复核人:"受理日期:初核日期:复核日期: