大病住院救助申请书

大病住院救助申请书申请人（以下简称“甲方”）：________Applicant(hereinafterreferredtoas"PartyA"):________鉴于甲方因________原因需要进行住院治疗，现向有关部门申请大病住院救助，特此提出如下申请书：InviewofthefactthatPartyAneedshospitalizationtreatmentdueto________reasons,PartyAherebyappliesformajorillnesshospitalizationassistanceandsubmitsthefollowingapplication:一、申请人信息I.ApplicantInformation1.1甲方姓名/名称：________1.1Name/NameofPartyA:________1.2甲方身份证号码：________1.2IDNumberofPartyA:________1.3甲方联系方式：________1.3ContactInformationofPartyA:________二、病情及治疗情况II.ConditionandTreatment2.1甲方的病情描述：________2.1DescriptionofPartyA'sillness:________2.2甲方的治疗计划：________2.2TreatmentPlanofPartyA:________三、费用情况III.CostSituation3.1甲方预计住院费用：________元3.1EstimatedhospitalizationcostsofPartyA:________yuan3.2甲方已支付费用：________元3.2AmountpaidbyPartyA:________yuan四、救助需求IV.AssistanceRequest4.1甲方请求相关部门提供大病住院救助，以减轻治疗费用负担。4.1PartyArequeststhattherelevantdepartmentprovidemajorillnesshospitalizationassistancetoalleviatetheburdenoftreatmentcosts.五、其他信息V.OtherInformation5.1甲方已提交相关证明材料，包括医院出具的诊断证明、医疗费用单据等。5.1PartyAhassubmittedrelevantproofmaterials,includingdiagnosiscertificatesissuedbythehospitalandmedicalexpensereceipts.六、声明VI.Statement6.1甲方承诺所提供信息真实、准确、完整，如有虚假信息，愿承担相应法律责任。6.1PartyAherebydeclaresthattheinformationprovidedistrue,accurate,andcomplete.Ifthereareanyfalsestatements,PartyAiswillingtobearthecorrespondinglegalresponsibilities.申请人（签字）：________PartyA(Signature):________申请日期：________DateofApplication:________注：本申请书仅供参考，具体内容请根据实际情况和当地政策进行调整。Note:Thisapplicationisforreferenceonly,andthes