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

1 - Registro ANS

ANS-n34665-9

3 - N Guia Principal

4 - Data da Autorizao

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5-Senha

6 - Data Validade da Senha

7 - Data de Emisso da Guia

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DADOS DO BENEFICIRIO
9- Plano

8 - Nmero da Carteira

10 - Validade da Carteira

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11 - Nome

12 - Nmero do Carto Nacional de Sade

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DADOS DO CONTRATADO SOLICITANTE

13 - Cdigo na Operadora / CNPJ / CPF

14 - Nome do Contratado

15 - Cdigo CNES

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16 - Nome do Profissional Solicitante

17 - Conselho Profissional

18 - Nmero no Conselho

19 - UF

20 - Cdigo CBO S

DADOS DA SOLICITAO / PROCEDIMENTOS E EXAMES SOLICITADOS

21 - Data/Hora da Solicitao

22 - Carter da Solicitao

25-Tabela

23 - CID 10

|___|___|:|___|___| |___| E-EletivaU -Urgncia/Emergncia

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26- Cdigo do Procedimento

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

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27 - Descrio

28.Qt.Solic. 29-Qt.Autoriz.

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DADOS DO CONTRATADO EXECUTANTE

30 - Cdigo na Operadora / CNPJ / CPF

31 - Nome do Contratado

32-T.L. 33-34-35-Logradouro - Nmero - Complemento 36 - Municpio

37 - UF 38 - Cd. IBGE 39 - CEP

40- Cdigo CNES

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40a - Cdigo na Operadora / CNPJ / CPF do exec. com 41 - Nome do Profissional Executante/Complementar

42 - Conselho Profissional

43 - Nmero no Conselho

44 - UF

45 - Cdigo CBO S

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45a - Grau de Participao

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DADOS DO ATENDIMENTO
47 - Indicao de Acidente
46-Tipo Atendimento
01 - Remoo 02 - Pequena Cirurgia 03 - Terapias 04 - Consulta 05 - Exame 06 - Atendimento Domiciliar
|___| 0 - Acidente ou doena relacionado ao trabalho 1- Trnsito
|___|___| 07- SADT Internado 08 - Quimioterapia 09 - Radioterapia 10 -TRS-Terapia Renal Substitutiva

48 - Tipo de Sada
2 - Outros

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

CONSULTA REFERNCIA
49 -Tipo de Doena
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A - Aguda C - Crnica

50 -Tempo de Doena
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A - Anos M- Meses D - Dias

PROCEDIMENTOS E PROCEDIMENTOS EM SRIE

51-Data

52-Hora Inicial

53-Hora Final

54-Tabela 55-Cdigo do Procedimento

56-Descrio

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

61-Valor Unitrio - R$

62-Valor Total - R$

1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|

___________________________________________________ |___|___|

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2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|

___________________________________________________ |___|___|

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3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|

___________________________________________________ |___|___|

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4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|

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5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|

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63-Data e Assinatura de Procedimentos em Srie

1 - |___|___|/|___|___|/|___|___| _________________________

3 - |___|___|/|___|___|/|___|___| _________________________

5 - |___|___|/|___|___|/|___|___| ______________________

7 - |___|___|/|___|___|/|___|___| ______________________

9 - |___|___|/|___|___|/|___|___| ______________________

2 - |___|___|/|___|___|/|___|___| _________________________

4 - |___|___|/|___|___|/|___|___| _________________________

6 - |___|___|/|___|___|/|___|___| ______________________

8 - |___|___|/|___|___|/|___|___| ______________________

10 - |___|___|/|___|___|/|___|___| ______________________

64 - Observao

65 - Total Procedimentos R$
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86 - Data e Assinatura do Solicitante

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66 - Total Taxas e Aluguis R$

67- Total Materiais R$

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68 - Total Medicamentos R$
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87 - Data e Assinatura do Responsvel pela Autorizao

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69 - Total Dirias R$
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70 - Total Gases Medicinais R$

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71 - Total Geral da Guia R$

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88-Data e Assinatura do Beneficirio ou Responsvel

89- Data e Assinatura do Prestador Executante

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OPM SOLICITADOS
72-Tabela 73-Cdigo do OPM

75-Qtde. 76-Fabricante

77- Valor Unitrio R$

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74-Descrio OPM

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__________________________________________________________________________

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2-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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3-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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4-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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5-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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6-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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7-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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8-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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9-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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__________________________________________________________________________

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OPM UTILIZADOS
78-Tabela 79-Cdigo do OPM

81-Qtde. 82-Cdigo de Barras

83- Valor Unitrio R$

1-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

80-Descrio OPM

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________________________________________

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84- Valor Total R$

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________________________________________

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3-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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4-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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5-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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6-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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7-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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8-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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9-|___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________

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________________________________________

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85- Total OPM R$

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INSTRUO
Os campos no sombreados so de preenchimento obrigatrio.