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["附件6"]
["一体化管理村卫生室申请医保定点评估表"]
["村卫生室名称（章）：                                         评估时间："]
["一体化管理的上级医疗机构名称"]
["评估项目","评估标准","评估情况"]
["功能定位和基本配备","是否具备与服务功能相适应的基础设施和仪器设备。“否”即为不合格"]
["专业技术人员","是否具备至少1名第一注册地在该医疗机构的医师。“否”即为不合格"]
["服务便民","是否环境整洁、就医秩序良好。“否”即为不合格"]
["医保联网结算","是否可实现与医保信息系统有效对接，为参保人员提供直接联网结算。“否”即为不合格"]
["采购销售国家、省集采药品","是否采购国家和省集采药品品种数量大于等于30种（按照通用名统计，不区分规格包装），并设置集采药品专柜且标识醒目，集采价格公示设置双价签（标注集采价格和零售价格），配备集采药品销售价格不高于集采中选价格。“否”即为不合格"]
["备注：评估项目全部合格的，评估结果即为合格；否则，评估结果即为不合格。"]
["评估结果"]
["评估人员签名：                                                                    被评估申请单位负责人员签名："]
[" "]
[" "]

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