Mu TK1-TS

(Ban hnh km theo Q s: 595/Q-BHXH

ngy 14/4/2017 ca BHXH Vit Nam)

BO HIM X HI VIT NAM CNG HA X HI CH NGHA VIT NAM

------- c lp - T do - Hnh phc
---------------

T KHAI
THAM GIA, IU CHNH THNG TIN BO HIM X HI, BO HIM Y T
Knh gi: ........................................................................
I. Phn k khai bt buc
[01]. H v tn (vit ch in hoa):................................................................................................
[02]. Ngy, thng, nm sinh: .././ [03]. Gii tnh:
[04]. Quc tch [05]. Dn tc: ..
[06]. Ni ng k giy khai sinh: [06.1]. X (phng, th trn): .
[06.2]. Huyn (qun, th x, Tp thuc tnh): ..[06.3]. Tnh (Tp): ..
[07]. a ch nhn h s: [07.1]. S nh, ng ph, thn xm: ..
[07.2]. X (phng, th trn): .[07.3] Huyn (qun, th x, Tp thuc tnh):
[07.4].Tnh (Tp): ..
[08]. H tn cha/ m/ ngi gim h (i vi tr em di 6 tui): .
II. Phn k khai chung
[09]. M s BHXH ( cp): .. [09.1]. S in thoi lin h: .
[09.2]. S CMND/ H chiu/ Th cn cc: ...
[10]. M s h gia nh ( cp): ..
(trng hp cha c m h gia nh th k khai b sung Ph lc nh km t khai)
[11]. Mc tin ng: .. [12]. Phng thc ng: .
[13]. Ni ng k khm bnh, cha bnh ban u:
[14]. Ni dung thay i, yu cu:......

[15]. H s km theo (nu c): ..

XC NHN CA N V Ti cam oan nhng ni dung k khai l ng

(ch p dng i vi ngi lao ng thay i h, v chu trch nhim trc php lut v nhng
tn m, tn; ngy, thng, nm sinh) ni dung k khai
.., ngy . thng nm .
Ngi k khai
(K, ghi r h tn)
 Ph lc: Thnh vin h gia nh
H v tn ch h: ... S in thoi (nu
c):...;
S s h khu (hoc s tm tr):... a ch: Thn (bn, t dn ph)
.X (phng, th trn) .. Huyn (qun, th x, Tp thuc tnh):
.. Tnh (Tp): ..
S CMND/
Mi quan
M s Ngy, thng, Gii Ni cp giy khai Th cn
Stt H v tn h vi Ghi ch
BHXH nm sinh tnh sinh cc/ H
ch h
chiu
A B 1 2 3 4 5 6 7
1
2
3
4
...
(Ghi ch: Ngi k khai c th tra cu M s BHXH v M h gia nh ti a ch:
http://baohiemxahoi.gov.vn)
Ti cam oan nhng ni dung k khai l ng v
chu trch nhim trc php lut v nhng ni dung
k khai
.., ngy . thng nm .
Ngi k khai
(K, ghi r h tn)
---------------------------------------

HNG DN LP
T khai tham gia, iu chnh thng tin bo him x hi, bo him y t
(Mu TK1-TS)
a) Mc ch:
- K khai cc thng tin ngi tham gia BHXH, BHYT, BHTN v thnh vin H gia nh khi khng c m
s BHXH.
- K khai khi c yu cu iu chnh thng tin tham gia BHXH, BHYT, BHTN, BHTNL-BNN nh: nhn
thn, chc danh ngh, phng thc ng, ni ng k KCB ban u ...
b) Trch nhim lp:
- Ngi tham gia BHXH, BHYT, BHTN, BHTNL-BNN.
- Cha/m/ngi gim h (i vi Tr em di 6 tui).
c) Thi gian lp:
- i vi ngi lao ng cng tham gia BHXH, BHYT, BHTNL-BNN; ngi ch tham gia BHXH bt
buc; ngi tham gia BHXH t nguyn: Khi tham gia khi cha c cp m s BHXH hoc iu chnh
thng tin tham gia BHXH, BHYT, BHTN, BHTNL, BNN.
- i vi ngi ch tham gia BHYT:
+ Tr em di 6 tui cha c cp th BHYT;
+ Ngi tham gia khi c iu chnh thng tin; ngi tham gia cha c cp m s BHXH.
d) Phng php lp:
[01]. H v tn: ghi y h, ch m v tn bng ch in hoa c du ca ngi tham gia BHXH,
BHYT, BHTN, BHTNL-BNN
[02]. Ngy thng nm sinh: ghi y ngy thng nm sinh nh trong giy khai sinh hoc chng minh
nhn dn, h chiu, th cn cc.
[03]. Gii tnh: ghi gii tnh ca ngi tham gia (nu l nam th ghi t nam hoc nu l n th ghi t
n).
[04]. Quc tch: ghi nh trong giy khai sinh hoc chng minh nhn dn, h chiu, th cn cc.
[05]. Dn tc: ghi nh trong giy khai sinh hoc chng minh nhn dn, h chiu, th cn cc.
[06]. Ni ng k Giy khai sinh: ghi r tn x (phng, th trn); huyn (qun, th x, thnh ph thuc
tnh), tnh, thnh ph ng k giy khai sinh.
Trng hp cha xc nh c ni cp giy khai sinh ln u th ghi nguyn qun (trng hp st
nhp, chia tch a gii hnh chnh th ghi theo tn a danh ti thi im k khai) hoc ghi theo ni ng
k h khu thng tr hoc tm tr.
[07]. a ch nhn h s: ghi y a ch ni ang sinh sng c quan BHXH gi tr s BHXH, th
BHYT hoc kt qu gii quyt th tc hnh chnh khc: s nh, ng ph, thn xm; x (phng, th
trn); huyn (qun, th x, thnh ph thuc tnh); tnh, thnh ph.
[08]. H tn cha hoc m, hoc ngi gim h (p dng i vi tr em di 6 tui): Ghi h tn cha hoc
m hoc ngi gim h.
[09]. M s BHXH: ghi m s BHXH c c quan BHXH cp (ch p dng i vi trng hp
c cp m s BHXH khi iu chnh thng tin); trng hp khng nh m s BHXH th ngi k khai
c th tra cu m s BHXH ti Bu in vn ha x hoc a ch: http://baohiemxahoi.gov.vn hoc phi
hp vi C quan BHXH hoc n v s dng lao ng, UBND x, i l thu/nh trng, C s tr gip
x hi, C s nui dng, iu dng thng binh v ngi c cng; C s gio dc ngh nghip
thuc ngnh lao ng, thng binh v x hi v c quan qun l i tng xc nh m s BHXH.
Trng hp khng xc nh c m s BHXH m c s s BHXH hoc s th BHYT th ghi s s
BHXH hoc s th BHYT.
Trng hp xc nh c m s BHXH nhng khc s s BHXH th ghi m s BHXH vo ch tiu ny
v ghi b sung s s BHXH vo ch tiu [14].
[09.1]. S in thoi lin h: ghi s in thoi lin h (nu c).
[09.2]. S chng minh nhn dn/H chiu/Th cn cc: ghi s chng minh nhn dn hoc ghi s h
chiu hoc ghi s Th cn cc.
[10]. M h gia nh: ghi m h gia nh c c quan BHXH cp (ch p dng i vi trng hp
c cp m s BHXH khi iu chnh thng tin); trng hp khng nh m s BHXH th ngi k
khai c th tra cu m s BHXH ti a ch: http://baohiemxahoi.gov.vn hoc phi hp vi C quan
BHXH hoc n v s dng lao ng, UBND x, i l thu/nh trng, C s tr gip x hi, C s nui
dng, iu dng thng binh v ngi c cng; C s gio dc ngh nghip thuc ngnh lao ng,
thng binh v x hi v c quan qun l i tng xc nh m h gia nh.
[11]. Mc tin ng (p dng i vi ngi tham gia BHXH t nguyn): ghi mc thu nhp thng do ngi
tham gia BHXH t nguyn la chn.
[12]. Phng thc ng (p dng i vi ngi i lao ng nc ngoi, ngi tham gia BHXH t
nguyn): ghi c th phng thc ng l 03 thng hoc 06 thng hoc 12 thng ...
[13]. Ni ng k KCB ban u: ghi ni ng k khm bnh, cha bnh BHYT ban u (danh sch ng
k ni KCB ban u c c quan BHXH thng bo hng nm gi cho cho n v, UBND x, i l thu).
[14]. Ni dung thay i, yu cu: ghi ni dung yu cu thay i nh: h tn, ngy thng nm sinh, cc
thng tin lin quan n chc danh, ngh nghip, cng vic, phng thc ng, ni ng k KCB ban
u ...
[15]. H s km theo:
- i vi ngi iu chnh thng tin, ghi cc loi giy t chng minh.
- i vi ngi tham gia c hng quyn li BHYT cao hn, ghi cc loi giy t chng minh.
Sau khi hon tt vic k khai, ngi tham gia k ghi r h tn. Trng hp k khai thay i v nhn thn
(h, tn m, tn; ngy, thng, nm sinh, gii tnh) ghi trn s BHXH, th BHYT th phi c xc nhn
ca n v ni ngi lao ng ang lm vic. i vi ngi ang bo lu thi gian ng BHXH th
khng phi xc nhn.
Ph lc: Thnh vin h gia nh
a) Mc ch: K khai y , chnh xc thng tin ton b thnh vin h gia nh trong s h khu hoc s
tm tr ca ngi tham gia.
b) Trch nhim lp:
- Ngi tham gia hoc ch h hoc ngi i din h gia nh.
- Cha/m/ngi gim h (i vi Tr em di 6 tui).
c) Thi gian lp: khi ngi tham gia BHXH, BHYT, BHTN, BHTNL-BNN cha c cp m s BHXH.
d) Cn c lp: s h khu hoc s tm tr, giy t lin quan n tham gia BHXH, BHYT, BHTN,
BHTNL-BNN;
) Phng php lp:
* Phn thng tin chung: ghi y h v tn ch h; ghi s s h khu (hoc s s tm tr); s in thoi
lin h (nu c); ghi r a ch: thn (bn, t dn ph); x (phng, th trn); huyn (qun, th x, thnh
ph thuc tnh); tnh (thnh ph).
Trng hp h gia nh ch c giy tm tr th vn thc hin k khai nhng ghi r cm t giy tm tr
vo ct ghi ch.
* Ch tiu theo ct:
- Ct A: ghi s th t t 1 n ht cc thnh vin trong h gia nh.
- Ct B: ghi y h v tn ca tng ngi trong s h khu (tr nhng ngi tm vng) hoc s tm
tr (bao gm ch h v cc thnh vin trong h).
- Ct 1: ghi m s BHXH i vi tng thnh vin h gia nh c c quan BHXH cp; trng trng
hp cha xc nh c m s BHXH th ngi k khai c th tra cu m s BHXH ti a ch:
http://baohiemxahoi.gov.vn (nu iu kin).
- Ct 2: ghi ngy, thng, nm sinh nh trong giy khai sinh hoc chng minh nhn dn, h chiu, th cn
cc.
- Ct 3: ghi gii tnh ca cc thnh vin trong h (nu l nam thi ghi t nam hoc nu l n th ghi t
n).
- Ct 4: ghi r tn x (phng, th trn); huyn (qun, th x, thnh ph thuc tnh); tnh, thnh ph cp
giy khai sinh.
Trng hp cha xc nh c ni cp giy khai sinh th ghi nguyn qun (trng hp st nhp, chia
tch a gii hnh chnh th ghi theo tn a danh ti thi im k khai) hoc ghi theo ni ng k h
khu thng tr hoc tm tr.
- Ct 5: ghi mi quan h vi ch h (l v, chng, con, chu...).
- Ct 6: S chng minh nhn dn/H chiu/Th cn cc (nu c): ghi s chng minh nhn dn hoc ghi
s h chiu hoc ghi s Th cn cc.
- Ct 7: ghi nhng ni dung cn ghi ch.
Sau khi hon tt vic k khai, ngi k khai k ghi r h tn.