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GUIA DE SERVI?O PROFISSIONAL / SERVI?O AUXILIAR DE DIAGN?STICO E TERAPIA - SP/SADT

2- N? Guia no Prestador ( O n?mero da guia tem que criado pelo Prestador )

1 - Registro ANS

3 ? N?mero da Guia Principal

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

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

4 - Data da Autoriza??o

5-Senha

6 - Data de Validade da Senha

|___|___| / |___|___| / |___|___|___|___| Dados do Benefici?rio 8 - N?mero da Carteira

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

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

9 - Validade da Carteira

10 - Nome

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

Dados do Solicitante

13 - C?digo na Operadora

14 - Nome do Contratado

7 - N?mero da Guia Atribu?do pela Operadora |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

11 - Cart?o Nacional de Sa?de |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

12 -Atendimento a RN |___|

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

15 - Nome do Profissional Solicitante

16 - Conselho Profissional

|___|___|

17 - N?mero no Conselho |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

18 ? UF |___|___|

19 - C?digo CBO |___|___|___|___|___|___|

20 - Assinatura do Profissional Solicitante

Dados da Solicita??o / Procedimentos ou Itens Assistenciais Solicitados

21 - Car?ter do 22 - Data da Solicita??o

Atendimento |___|

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

23 - Indica??o Cl?nica

24-Tabela Aut.

1 - |___|___|

25- C?digo do Procedimento

26 - Descri??o

ou Item Assistencial |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________

2 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________

3 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________

4 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________

5 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________

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

27-Qtde. Solic.

28- Qtde.

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

Dados do Contratado Executante 29 - C?digo na Operadora

30 - Nome do Contratado

31 - C?digo CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| Dados do Atendimento 32-Tipo de Atendimento 33 - Indica??o de Acidente (acidente ou doen?a relacionada)

34 - Tipo de Consulta

35 - Motivo de Encerramento do Atendimento

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

|___|___|

|___|

|___|

|___|___|

Dados da Execu??o / Procedimentos e Exames Realizados

36-Data

37-Hora Inicial 38-Hora Final 39-Tabela 40-C?digo do Procedimento 41-Descri??o

42 - Qtde. 43-Via 44-Tec. 45- Fator Red./Acresc. 46-Valor Unit?rio (R$)

47-Valor Total (R$)

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

|___|,|___|___|

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

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

|___|,|___|___|

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

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

|___|,|___|___|

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

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

|___|,|___|___|

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

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

|___|,|___|___|

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

Identifica??o do(s) Profissional(is) Executante(s) 48-Seq.Ref 49-Grau Part. 50-C?digo na Operadora/CPF

|___|___|

|___|___|

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

51-Nome do Profissional

52-Conselho 53-N?mero no Conselho

54-UF 55-C?digo CBO

Profissional

________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

|___|___|

|___|___|

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

56-Data de Realiza??o de Procedimentos em S?rie 57-Assinatura do Benefici?rio ou Respons?vel 1- |___|___|/|___|___|/|___|___|___|___| __________________ 3 - |___|___|/|___|___|/|___|___|___|___| __________________ 5 - |___|___|/|___|___|/|___|___|___|___| _______________ 7 - |___|___|/|___|___|/|___|___|___|___| _______________ 2- |___|___|/|___|___|/|___|___|___|___| __________________ 4 - |___|___|/|___|___|/|___|___|___|___| __________________ 6 - |___|___|/|___|___|/|___|___|___|___| _______________ 8 - |___|___|/|___|___|/|___|___|___|___| _______________

9 - |___|___|/|___|___|/|___|___|___|___| _________________ 10 - |___|___|/|___|___|/|___|___|___|___| ________________

58-Observa??o / Justificativa

59 - Total de Procedimentos (R$)

60 - Total de Taxas e Alugu?is (R$)

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

66 - Assinatura do Respons?vel pela Autoriza??o

61 - Total de Materiais (R$) |___|___|___|___|___|___|___|___|,|___|___|

62- Total de OPME (R$) |___|___|___|___|___|___|___|___|,|___|___|

67 - Assinatura do Benefici?rio ou Respons?vel

63 - Total de Medicamentos (R$)

64 - Total de Gases Medicinais (R$)

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

68 - Assinatura do Contratado

65 - Total Geral (R$) |___|___|___|___|___|___|___|___|,|___|___|

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