GUIA DE CONSULTA

2- N Guia no Prestador

1 - Registro ANS 3 - Nmero da Guia Atribudo pela Operadora

31.292-4 |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Dados do Benecirio
4 - Nmero da Carteira 5 - Validade da Carteira 6 Atendimento a RN (Sim ou No)

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7 Nome 8 - Carto Nacional de Sade

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Dados do Contratado
9- Cdigo na Operadora 10 - Nome do Contratado 11 - Cdigo CNES

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12 - Nome do Prossional Executante 13 - Conselho 14 - Nmero no Conselho 15 - UF 16 - Cdigo CBO

Prossional |___|___|
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Dados do Atendimento / Procedimento Realizado

17 - Indicao de Acidente (acidente ou doena relacionada)

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18 - Data do Atendimento 19 - Tipo de Consulta 20 - Tabela 21 - Cdigo do Procedimento 22 - Valor do Procedimento

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23 - Observao / Justicativa

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24 - Assinatura do Prossional Executante 25 - Assinatura do Benecirio ou Responsvel

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