Escolar Documentos
Profissional Documentos
Cultura Documentos
CNPJ: 61.849.980/0001
1-Registro ANS 3-N da Guia Principal
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325074
Dados do Beneficirio
8-Numero da Carteira
GAEP 11/853.402
4-Data da Autorizao
5-Senha
1 3 / .__.__.
0 9 / .__.__.
1 1
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11666813
1 2 / .__.__.
1 1 / .__.__.
1 1
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1 3 / .__.__.
0 9 / .__.__.
1 1
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9-Plano
P 0 0 0 0 0 0 3 8 0 2 4 2 0 0
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Dados do Contratado Solicitante
13-Cdigo na Operadora / Cnpj / Cpf
2-N:
10-Validade da Carteira
11-Nome
14-Nome do Contratado
0 0 0 0 2
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15-Cdigo CNES
5187605
17-Conselho
Profissional
19-UF
20-Cdigo CBO S
1 3 0 9 1 1
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|__|__|:|__|__|
12345-
1 6
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1 6
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1 6
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22-Carcter da Solicitao
E E - Eletiva U - Urgncia / Emegncia
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27-Descrio
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4 0 1 0 3 0 7 2
.__.__.__.__.__.__.__.__.__.__.
4 0 1 0 3 4 3 9
.__.__.__.__.__.__.__.__.__.__.
4 0 1 0 3 0 9 9
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23-CID 10
24-Indicao Clnica (obrigatrio se pequena cirurgia, terapia, consulta referenciada e alto custo)
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28-Qt.Solic. 29-Qt.Autor
_______________________________________________________________________________________________________
AUDIOMETRIA TONAL LIMIAR COM TESTES DE DISCRIMINAO
_______________________________________________________________________________________________________
IMPEDANCIOMETRIA
_______________________________________________________________________________________________________
AUDIOMETRIA VOCAL - PESQUISA DE LIMIAR DE DISCRIMINAO
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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1
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1
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1
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1
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1
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1
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0 7 5 1 1
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COI
36-Municpio
3032-0501/ 3034-1695
37UF
SP
SAO PAULO
42-Conselho Profis.
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43-Nmero no
Conselho
38-Cd.IBGE
44UF
39-Cep
40-Cdigo CNES
05428040
5718619
45-Cdigo CBO
S
45a-Grau de
Participao
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Dados do Atendimento
46-Tipo de Atendimento
47-Indicao de Acidente
48-Tipo de Sada
.__. 1-Retorno 2-Retorno SADT 3-Referncia
4-Internao 5-Alta 6-bito
Consulta Referncia
49-Tipo de Doena
.__. A - Aguda
C - Crnica
50-Tempo de Doena
.__.__. .__. A - Anos
M - Meses
D - Dias
.__.
.__.
.__.
.__.
1- .__.__./.__.__./.__.__. ____________ 3- .__.__./.__.__./.__.__. ____________ 5- .__.__./.__.__./.__.__. ____________ 7- .__.__./.__.__./.__.__. _____________ 9- .__.__./.__.__./.__.__. __________
2- .__.__./.__.__./.__.__. ____________ 4- .__.__./.__.__./.__.__. ____________ 6- .__.__./.__.__./.__.__. ____________ 8- .__.__./.__.__./.__.__. _____________10- .__.__./.__.__./.__.__. __________
64-Observao
ATENDIMENTO 24 HORAS 3674-7000
CONFIRMAR SENHA NO ATO DA INTERNAO EM CASO DE UTI, SOLICITAR AUTORIZAO
SEM COBERTURA PARA PROTESE, RTESES E
PRORROGAO SUJEITA A RELATRIO MDIC OBSERVAR DATA DE VALIDADE DA GUIA
P/ ALTERAO PROCEDIMENTO SOLICITAR AUTS/COBERTURA P/MATERIAIS/MEDICAMENTOS IM
65-Total de Procedimentos R$ 66-Total de Taxas e Aluguis
.__.__.__.__.__.__.__. , .__.__. R$
.__.__.__.__.__.__.__. , .__.__.
67-Total de Materiais R$
.__.__.__.__.__.__. , .__.__.
68-Total de Medicamentos R$
.__.__.__.__.__.__.__. , .__.__.
69-Total Dirias R$
70-Total Gases Medicinais R$ 71-Total Geral da Guia R$
.__.__.__.__.__.__. , .__.__. .__.__.__.__.__.__. , .__.__.
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1 3 / .__.__.
0 9 / .__.__.
1 1 CAMILA
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