第四师可克达拉市医疗保障局

                     检查笔录

时间：      年   月   日   时   分至       年   月   日   时   分

检查地点：                                                       

被检查人姓名或名称：                                             

被检查人身份证号或统一社会信用代码：                             

联系电话：                                                      

见证人姓名：                        联系电话：                  

见证人身份证号码：                                              

执法人员表明身份、出示证件及被检查人确认的记录：执法人员（问）：

我们是         医疗保障局的行政执法人员                         

、           ，这是我们的执法证，编号                           、

                         ，请过目确认：                          。

今天我们依法进行检查并了解有关情况，你（单位）应当配合检查，如实提

供材料，不得拒绝、阻碍、隐瞒或者提供虚假情况。如果你认为检查人员与

本案有利害关系，可能影响公正办案，可以申请回避，并说明理由。你（单

位）是否申请检查人员回避：□申请回避；□不申请回避。

你（单位）有权对本次检查提出陈述、申辩。

被检查人的陈述、申辩意见：                                       

                                                                     

                                                                     

检查情况：                                                       

                                                                     

被检查人签名：                                      年   月   日

检查人签名：                                        年   月   日

记录人签名：                                        年   月   日

见证人签名：                                        年   月   日

                                   第   页 共   页

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

被检查人签名：                                      年   月   日

检查人签名：                                        年   月   日

记录人签名：                                        年   月   日

见证人签名：                                        年   月   日

                                   第   页 共   页

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

被检查人阅读确认意见：                                          

见证人阅读确认意见：                                            

被检查人签名：                                      年   月   日

检查人签名：                                        年   月   日

记录人签名：                                        年   月   日

见证人签名：                                        年   月   日

                                   第   页 共   页