GUIA DE SERVIO PROFISSIONAL/SERVIO AUXILIAR DE DIAGNSTICO E TERAPIA-SP/SADT

7605212-8

2 -N

1 - Registro ANS

34.692-6

5 - Senha

3 - N Guia Principal

4 - Data de Autorizao

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Dados do Beneficirio
8 - Nmero da Carteira

9 - Plano

7 - Data de Emisso da Guia

6 - Data Validade da Senha

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11 - Nome

10 - Validade da Carteira

12 - Nmero do Carto Nacional de Sade

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Dados do Contratado Solicitante

14 - Nome do Contratado

13 - Cdigo na Operadora/CNPJ/CPF

15 -Cdigo CNES

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16 - Nome do Profissional Solicitante

17 - Conselho Profissional

19 - UF

18 - Nmero no Conselho

20 - Cdigo CBOS

Dados da Solicitao/Procedimento e Exames Solicitados

21 - Data/Hora da Solicitao

22 - Carter da Solicitao

23 - CID10

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E - Eletiva U - Urgncia/Emergncia

24 - Indicao Clnica(obrigatrio se pequena cirurgia, terapia, consulta referenciada e alto custo)

25-Tabela

26 -Cdigo do Procedimento

27 - Descrio

1 - |_ _ _ |_ _ _ |

|_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |__ _ _ |_ _ _ |_ _ _ |

___ __ __ _ __ __ ___ _ __ __ __ ___ __ _ __ __ __ __ __ __ __ __ ___ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ___ __ __ __ __ _ ___ __ __ _ __ ___ __ __ __ _ __ ___ __ _ __ __ ___ __ __ _ __ __ ___ _ __ __ __ ___ __ _ __ __ __ __ __ __ __ __ ___ _

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2 -|_ _ _ |_ _ _ |

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_ _ __ __ __ __ ___ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ___ __ __ __ __ __ __ __ __ _ __ ___ __ __ __ _ ___ __ __ _ __ __ ___ __ __ _ __ ___ __ _ __ __ __ ___ __ _ __ __ ___ _ __ __ __ ___ __ _ __ __ __ __ __ __ __ __ ___ _ __ __ __ __ __ __ __

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3 -|_ _ _ |_ _ _ |

|_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |__ _ _ |_ _ _ |_ _ _ |

_ _ __ __ __ __ ___ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ___ __ __ __ __ __ __ __ __ _ __ ___ __ __ __ _ ___ __ __ _ __ __ ___ __ __ _ __ ___ __ _ __ __ __ ___ __ _ __ __ ___ _ __ __ __ ___ __ _ __ __ __ __ __ __ __ __ ___ _ __ __ __ __ __ __ __

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4 -|_ _ _ |_ _ _ |

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_ _ __ __ __ __ ___ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ___ __ __ __ __ __ __ __ __ _ __ ___ __ __ __ _ ___ __ __ _ __ __ ___ __ __ _ __ ___ __ _ __ __ __ ___ __ _ __ __ ___ _ __ __ __ ___ __ _ __ __ __ __ __ __ __ __ ___ _ __ __ __ __ __ __ __

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5 -|_ _ _ |_ _ _ |

|_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |_ _ _ |__ _ _ |_ _ _ |_ _ _ |

_ _ __ __ __ __ ___ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ___ __ __ __ __ __ __ __ __ _ __ ___ __ __ __ _ ___ __ __ _ __ __ ___ __ __ _ __ ___ __ _ __ __ __ ___ __ _ __ __ ___ _ __ __ __ ___ __ _ __ __ __ __ __ __ __ __ ___ _ __ __ __ __ __ __ __

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28-QtSolic.

29-Qt .Autoriz.

Dados do Contratado Executante

30 - Cdigo na Operadora/CNPJ/CPF

31 - Nome do Contratado

32-T.L.

41 - Nome do Profissional Executante/Complementar

42 - Conselho Profissional

37 - UF

36 - Municpio

33-34-35-Logradouro-Nmero-Compl.

38 - Cd.IBGE

40 - Cdigo CNES

39 - CEP

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40a - Cdigo na Operadora/CPF do Exec .Complementar

43 - Nmero no Conselho

44 - UF

45 - Cdigo CBOS

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45a - Grau de Participao

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Dados do Atendimento
46 - Tipo Atendimento

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48 - Tipo de Sada

47 - Indicao do Acidente

01 -Remoo 02 -Pequena Cirurgia 03 -Terapias 04 -Consulta 05 -Exame 06 -Atendimento Domiciliar

07 -SADT Internado 08 -Quimioterapia 09 -Radioterapia 10 -TRS-Terapia Renal Substitutiva

|___| 0 -Acidente ou doena relacionado ao trabalho

1 -Trnsito

|____| 1 -Retorno 2 -Retorno SADT 3 -Referncia 4 -Internao 5 -Alta 6 -bito

2 -Outros

Consulta -Referncia
49 -Tipo de Doena

50 -Tempo de Doena

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A -Aguda C -Crnica

A -Ano M -Ms D -Dia

Procedimentos e Exames Realizados

51 -Data

52 -Hora Inicial

53 -Hora Final

54 -Tabela

55 -Cdigo do Procedimento

57 -Qtde. 58-Via 59 -Tec. 60-%Red./Acresc.

56 -Descrio

61-Valor Unitrio-R$

62-Valor Total-R$

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63 -Data e Assinatura de Procedimentos em Srie

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__________________________ 10 -|___|___|/|___|___|/|___|___| _____________________

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64 - Observao

65 -Total Procedimentos R$

66 - Total Taxas e Aluguis R$

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86 - Data e Assinatura do Solicitante

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67 -Total Materiais R$
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87 - Data e Assinatura do Responsvel pela Autorizao

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68 -Total Medicamentos R$

69 -Total Dirias R$

70 -Total Gases Medicinais R$

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88 - Data e Assinatura do Beneficirio ou Responsvel

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71 -Total Geral da Guia R$

89 - Data e Assinatura do Prestador Executante

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