Mu s 16A-HSB

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
N NGH
CHUYN NI NHN LNG HU/TR CP
BO HIM X HI HNG THNG
Knh gi: Bo him x hi tnh/thnh ph ........................
Tn ti l: ..................................... sinh ngy .......... thng ........... nm ..........
S CMND ................................... cp ngy ......... thng ....... nm ............ ti ..
; s in thoi (nu c): ......................................
Theo h s hng BHXH, ti con c tn ........................................., sinh
ngy ....../....../.......(1)
Hin ang hng ch .................................................. ti a ch ....................
............................................................................................................................................
S h s ..................................................
S th BHYT hin ang s dng (nu c): ...............................................................
Ti lm n ny ngh Bo him x hi tnh/thnh ph ............................ ...........
gii quyt cho ti c chuyn n hng lng hu/tr cp BHXH hng thng ti ni
c tr mi theo a ch (2): ................................................................................................
......................................................................................................................................;
Ti xin ng k ni khm cha bnh bo him y t ban u ti
(3): .................. ................................................................................................................
.......................
Ti ngh c nh n lng hu qua ti khon c nhn ca ti nh sau: Ch ti
khon:, s ti khon:........, m ti Ngn hng
.., chi nhnh ..............................(4) ./.
.............., ngy ...... thng .....
.............., ngy ....... thng .....
nm .....
nm ......
Xc nhn ca chnh quyn
Ngi lm n
a phng ni c tr mi (4)
(K, ghi r h tn)
(K, ng du)

Ghi ch: - (1) Trng hp gia h s hng BHXH v CMND khng thng nht v ho tn, tn m
, ngy,
thng, nm sinh thi khai b sung n i dung ny, nu thng nht thi gch cheo;
- (2) Ghi y a ch: S nh, ng (ngch, hm), ng ph, t (thn, xm, p), x (phng, th
trn), huyn (th x, thnh ph), tnh, thnh ph;
- (3) Ni KCB ban u do c nhn la chon c s khm cha bnh c k hp ng khm cha bnh
bo him y t (Trm y t x, hoc Bnh vin a khoa huyn/tng ng, hoc cc c s KCB khc theo phn
cp ca ngnh Y t); nu thuc i tng ngi c cng vi cch mng thi ghi r thuc i tng ngi c cng
vi cch mng sau tn c s khm cha bnh ng k.
- (4) Trng hp c yu cu nhn lng hu qua ti khon c nhn thi ghi y thng tin vo ni
dung ny, nu khng thi gch cheo.

- (5) U ban nhn dn x, phng ni c tr mi xc nhn. Trng hp c bn sao h khu thng tr

hoc bn sao giy ng k tm tr ti ni c tr mi nh km thi khng cn xc nhn ca chnh quyn a phng.