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GUIA DE SOLICITAO DE INTERNAO

1 - Registro ANS

3 - Data da Autorizao

ANS-n34665-9

4 - Senha

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|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

5 - Data Val
idade da Senha

6 - Data de Emisso da Guia

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|___|___| /|___|___| /|___|___|

DADOS DO BENEFICIRIO
7 - Nmero da Carteira

8 - Pl
ano

9 - Val
idade da Carteira

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|___|___| /|___|___| /|___|___|

11 - Nmero do Carto Nacionalde Sade

10 - Nome

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

DADOS DO CONTRATADO SOLICITANTE


12 - Cdigo na Operadora /CNPJ/CPF

13 - Nome do Contratado

14 - Cdigo CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

16 - Consel
ho Profissional

15 - Nome do ProfissionalSol
icitante

17 - Nmero no Consel
ho

18 - UF

19 - Cdigo CBO S

DADOS DO CONTRATADO SOLICITADO /DADOS DA INTERNAO


21 - Nome do Prestador

20- Cdigo na Operadora /CNPJ


|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

22 - Carter da Internao

23-Tipo de Internao

|___| E - El
etiva U - Urgncia/Emergncia

|___|

1- Cl
nica 2- Cirrgia 3- Obsttrica 4- Peditrica 5- Psiquitrica

24 - Regime de Internao
|___|

25 - Qtde.DiariasSol
icitadas

1 - Hospital
ar 2 - Hospital
-dia

3 - Domicil
iar

|___|___|___|

26 - Indicao Cl
nica

HIPTESES DIAGNSTICAS
27-Tipo Doena
|___|

A - Aguda

C - Crnica

30-CID 10 Principal
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28-Tempo de Doena Referida pel


o Paciente

29 - Indicadao de Acidente

|___|___| - |__|

|___|

31 - CID 10 (2)
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A -Anos M -Meses

32 - CID 10 (3)

D -Dias

0 - Acidente ou doena rel


acionada ao Trabal
ho

1 - Trnsito

2 - Outros

33 - CID 10 (4)

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PROCEDIM ENTOS SOLICITADOS


34-Tabel
a 35 - Cdigo do Procedimento

36 - Descrio

37 - Qtde.Sol
ict 38 - Qtde.Aut

1-|___|___|

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_________________________________________________________________________________________________________________

|___|___|

|___|___|

2-|___|___|

|___|___|___|___|___|___|___|___|___|___|

_________________________________________________________________________________________________________________

|___|___|

|___|___|

3-|___|___|

|___|___|___|___|___|___|___|___|___|___|

_________________________________________________________________________________________________________________

|___|___|

|___|___|

4-|___|___|

|___|___|___|___|___|___|___|___|___|___|

_________________________________________________________________________________________________________________

|___|___|

|___|___|

5-|___|___|

|___|___|___|___|___|___|___|___|___|___|

_________________________________________________________________________________________________________________

|___|___|

|___|___|

OPM SOLICITADOS
39-Tabel
a 40-Cdigo do OPM

41-Descrio OPM

42-Qtde. 43-Fabricante

44-Val
or Unitrio R$

1-|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________ |___|___|

_____________________________________________________

|___|___|___|___|___|___|,|___|___|

2-|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________ |___|___|

_____________________________________________________

|___|___|___|___|___|___|,|___|___|

3-|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________ |___|___|

_____________________________________________________

|___|___|___|___|___|___|,|___|___|

4-|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________ |___|___|

_____________________________________________________

|___|___|___|___|___|___|,|___|___|

5-|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________ |___|___|

_____________________________________________________

|___|___|___|___|___|___|,|___|___|

DADOS DA AUTORIZAO
45 - Data Provvelda Admisso Hospital
ar
|___|___| /|___|___| /|___|___|

46 - Qtde.DiariasAutorizadas
|___|___|___|

48 - Cdigo na Operadora /CNPJ

47 - Tipo da Acomodao Autorizada


|___|___|

49 - Nome do Prestador autorizado

50 - Cdigo CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

51 - Observao

52-Data e Assinatura do Mdico Sol


icitante
|___|___| /|___|___| /|___|___|

INSTRUO
Oscamposno sombreadosso de preenchimento obrigatrio.

53-Data e Assinatura do Beneficirio ou Responsvel

54-Data e Assinatura do Responsvelpel


a Autorizao

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|___|___| /|___|___| /|___|___|

PRORROGAES
55-Data

56-Senha

57-Responsvelpel
a Autorizao

|___|___|/|___|___|/|___|___|

___________________________

________________________________________

58-Tipo Acomod 59-Acomodao

60-Qtde. Autorizada

|___|___|

|___|___|

_____________________________________________

61-Tabel
a 62 -Cdigo do Procedimento

63 -Descrio

64 -Qtde. sol
ic.

65 -Qtde. Aut

|___|___|

|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________________________ |___|___|

|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________________________ |___|___|

|___|___|

66-Tabel
a 67-Cdigo do OPM

68-Descrio OPM

69-Qtde.

70-Fabricante

71 -Val
or Unitrio R$

|___|___|

|___|___|___|___|___|___|___|___|___|___| ____________________________________________

|___|___|

____________________________________________

|___|___|___|___|___|___|,|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___| ____________________________________________

|___|___|

____________________________________________

|___|___|___|___|___|___|,|___|___|

55-Data

56-Senha

57-Responsvelpel
a Autorizao

|___|___|/|___|___|/|___|___|

___________________________

________________________________________

58-Tipo Acomod 59-Acomodao

60-Qtde. Autorizada

|___|___|

|___|___|

_____________________________________________

61-Tabel
a 62 -Cdigo do Procedimento

63 -Descrio

64 -Qtde. sol
ic.

65 -Qtde. Aut

|___|___|

|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________________________ |___|___|

|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________________________ |___|___|

|___|___|

66-Tabel
a 67-Cdigo do OPM

69-Qtde.

70-Fabricante

71 -Val
or Unitrio R$

|___|___|

|___|___|___|___|___|___|___|___|___|___| ____________________________________________

68-Descrio OPM

|___|___|

____________________________________________

|___|___|___|___|___|___|,|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___| ____________________________________________

|___|___|

____________________________________________

|___|___|___|___|___|___|,|___|___|

55-Data

56-Senha

|___|___|/|___|___|/|___|___|

___________________________

57-Responsvelpel
a Autorizao
________________________________________

58-Tipo Acomod 59-Acomodao


|___|___|

60-Qtde. Autorizada

_____________________________________________

61-Tabel
a 62 -Cdigo do Procedimento

|___|___|

63 -Descrio

64 -Qtde. sol
ic.

65 -Qtde. Aut

|___|___|

|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________________________ |___|___|

|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________________________ |___|___|

|___|___|

66-Tabel
a 67-Cdigo do OPM

68-Descrio OPM

69-Qtde.

70-Fabricante

71 -Val
or Unitrio R$

|___|___|

|___|___|___|___|___|___|___|___|___|___| ____________________________________________

|___|___|

____________________________________________

|___|___|___|___|___|___|,|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___| ____________________________________________

|___|___|

____________________________________________

|___|___|___|___|___|___|,|___|___|

INSTRUO
Os campos no sombreados so de preenchimento obrigatrio.