Documente Academic
Documente Profesional
Documente Cultură
Componenta prescriere
NMSKBF 22577 x MF
NMSKBF 22577 x MF
Serie ...................... Numar ...................................... Serie ...................... Numar ......................................
1. Unitate medicala AMBULATORIU 1. Unitate medicala AMBULATORIU
SC ERC MEDICIS SRL
........................................................................................ SC ERC MEDICIS SRL
........................................................................................
Adresa Adresa
SPITAL SPITAL
Târgu Mureş, BARTOK BELA, nr. 11/1, jud. MURES
........................................................................................... Târgu Mureş, BARTOK BELA, nr. 11/1, jud. MURES
...........................................................................................
34436390
CUI ................................. ROMANIA 34436390
CUI ................................. ROMANIA
CAS-MS / 410/42 ALTELE ..... CAS-MS / 410/42 ALTELE .....
CAS/Contract - conventie ...................................................... CAS/Contract - conventie ......................................................
Telefon / Fax medic prescriptor (cu prefixul de tara): 0040265220080 Telefon / Fax medic prescriptor (cu prefixul de tara): 0040265220080
Email medic prescriptor: dr.elencraciun@yahoo.com Email medic prescriptor: dr.elencraciun@yahoo.com
2. Asigurat 5712
FO/RC ..................... Salariat Revolutionar 2. Asigurat 5712
FO/RC ..................... Salariat Revolutionar
ŞOLDAN Co-asigurat Handicap ŞOLDAN Co-asigurat Handicap
Nume ............................................................................. Nume .............................................................................
ANA-VOICHIŢA Liber profesionist PNS ANA-VOICHIŢA Liber profesionist PNS
Prenume .......................................................................... Prenume ..........................................................................
Copil (<18 ani) Ajutor social Copil (<18 ani) Ajutor social
CID/CNP CID/CNP
Elev / Ucenic / Elev / Ucenic /
CE Somaj CE Somaj
4 0 1 0 9 5 3 8 4 9 6 4 8 9 2 5 6 7 9 4 Student (18 - 26 ani) 4 0 1 0 9 5 3 8 4 9 6 4 8 9 2 5 6 7 9 4 Student (18 - 26 ani)
PASS Personal contractual PASS Personal contractual
Gravida / Lehuza Gravida / Lehuza
03.08.1960
Data nasterii ............................. Card european (CE) 03.08.1960
Data nasterii ............................. Card european (CE)
x Pensionar
Acorduri
x Pensionar
Acorduri
Sexul M x F Cetatenia R O Veteran internationale
Sexul M x F Cetatenia R O Veteran internationale
Lista B 90% Alte categorii ........... Lista B 90% Alte categorii ...........
Pozitia
Cod Tip Tip Denumire comuna internationala / Denumire comerciala / Cantitate Numar zile % Pret Cod Tip Tip Denumire comuna internationala / Denumire comerciala / Cantitate Numar zile % Pret
D.S Lista D.S Lista
diag. diag. prescr. Forma Farmaceutica / Concentratie ( UT ) tratament ref. diag. diag. prescr. Forma Farmaceutica / Concentratie ( UT ) tratament ref.
1 453 C C BISOPROLOLUM /COMPR. FILM./5MG 1x1 90 ( nouazeci) 90 90 A 1 453 C C BISOPROLOLUM /COMPR. FILM./5MG 1x1 90 ( nouazeci) 90 90 A
2 453 C C COMBINATII (PERINDOPRILUM+INDAPAMIDUM) 1x1 90 ( nouazeci) 90 50 B 2 453 C C COMBINATII (PERINDOPRILUM+INDAPAMIDUM) 1x1 90 ( nouazeci) 90 50 B
Poz.
5.Justificare medicala prescriere denumire comerciala 5.Justificare medicala prescriere denumire comerciala