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

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

6-Data Validade da Senha

7-Data de Emisso da Guia

1 3 / .__.__.
0 9 / .__.__.
1 1
.__.__.

11666813

1 2 / .__.__.
1 1 / .__.__.
1 1
.__.__.

1 3 / .__.__.
0 9 / .__.__.
1 1
.__.__.

9-Plano

P 0 0 0 0 0 0 3 8 0 2 4 2 0 0
.__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.__. STYLE
Dados do Contratado Solicitante
13-Cdigo na Operadora / Cnpj / Cpf

2-N:

10-Validade da Carteira

11-Nome

12-Nmero do Carto Nacional de Sade


.__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.

.__.__./.__.__./.__.__. EDNEIA CALADO DE MEDEIROS

14-Nome do Contratado

0 0 0 0 2
.__.__.__.__.__.__.__.__.__.__.__.__.__.__.

15-Cdigo CNES

* PRONTO SOCORRO ITAMARATY REBOUAS

16-Nome do Profissional Solicitante

5187605
17-Conselho
Profissional

18-Nmero no Conselho Profissional

19-UF

20-Cdigo CBO S

Dados de Solicitao / Procedimentos e Exames Solicitados


21-Data Hora da Solicitao

1 3 0 9 1 1
|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

25-Tabela 26-Cdigo do procedimento

12345-

1 6
.__.__.
1 6
.__.__.
1 6
.__.__.
.__.__.
.__.__.

22-Carcter da Solicitao
E E - Eletiva U - Urgncia / Emegncia
|__|
27-Descrio

.__.__.__.__.__.__.__.__.__.__.
4 0 1 0 3 0 7 2
.__.__.__.__.__.__.__.__.__.__.
4 0 1 0 3 4 3 9
.__.__.__.__.__.__.__.__.__.__.
4 0 1 0 3 0 9 9
.__.__.__.__.__.__.__.__.__.__.
.__.__.__.__.__.__.__.__.__.__.

23-CID 10

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

|__|__|__|__|__|
28-Qt.Solic. 29-Qt.Autor

_______________________________________________________________________________________________________
AUDIOMETRIA TONAL LIMIAR COM TESTES DE DISCRIMINAO
_______________________________________________________________________________________________________
IMPEDANCIOMETRIA
_______________________________________________________________________________________________________
AUDIOMETRIA VOCAL - PESQUISA DE LIMIAR DE DISCRIMINAO
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

.__.__.
1
.__.__.
1
.__.__.
1
.__.__.
.__.__.

.__.__.
1
.__.__.
1
.__.__.
1
.__.__.
.__.__.

Dados do Contratado Executante


30-Cdigo na Operadora / CNPJ / CPF

31-Nome do Contratado Executante

0 7 5 1 1
.__.__.__.__.__.__.__.__.__.__.__.__.__.__.

COI

32-T.I. 33-34-35 Logradouro - Nmero - Complemento - Fone

36-Municpio

3032-0501/ 3034-1695

R.CD.SILVIO ALVARES PENTEADO, 64 - PINHEIROS


40a-Cd. na Operadora/Cpf do Exec.Complementar

41-Nome do Profissional Executante/Complementar

37UF
SP

SAO PAULO
42-Conselho Profis.

.__.__.__.__.__.__.__.__.__.__.__.__.__.__.

43-Nmero no
Conselho

38-Cd.IBGE
44UF

39-Cep

40-Cdigo CNES

05428040

5718619

45-Cdigo CBO
S

45a-Grau de
Participao
.__.__.

Dados do Atendimento
46-Tipo de Atendimento

47-Indicao de Acidente

0 5 01-Remoo 02-Pequena Cirurgia 03-Terapias 04-Consulta 05-Exame 06-Atendimento Domicliar


.__.__.
07-SADT internado 08-Quimioterapia 09-Radioterapia 10-TRS Terapia Renal Substitutiva

2 0 - Acidente ou Doena relacionado ao Trabalho


.__.
1 - Trnsito 2 - Outros

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

Procedimentos e Exames Realizados


51-Data
5960-%Red./Acrsc. 61-Valor Unitrio-R$
62-Valor Total -R$
53-Hora Final 54-Tab. 55-Cdigo do procedimento
56-Descrio
57-Qtde 58-Via
52-Hora Inicial
1- .__.__./.__.__./.__.__. .__.__.:.__.__.a .__.__.:.__.__. .__.__. .__.__.__.__.__.__.__.__.__.__. _________________ .__.__. .__. Tec.
.__. .__.__.__.,.__.__. .__.__.__.__.__.,.__.__. .__.__.__.__.__.,.__.__.
2- .__.__./.__.__./.__.__. .__.__.:.__.__.a .__.__.:.__.__. .__.__. .__.__.__.__.__.__.__.__.__.__. _________________ .__.__. .__.
3- .__.__./.__.__./.__.__. .__.__.:.__.__.a .__.__.:.__.__. .__.__. .__.__.__.__.__.__.__.__.__.__. _________________ .__.__. .__.
4- .__.__./.__.__./.__.__. .__.__.:.__.__.a .__.__.:.__.__. .__.__. .__.__.__.__.__.__.__.__.__.__. _________________ .__.__. .__.
5- .__.__./.__.__./.__.__. .__.__.:.__.__.a .__.__.:.__.__. .__.__. .__.__.__.__.__.__.__.__.__.__. _________________ .__.__. .__.

.__.
.__.
.__.
.__.

.__.__.__.,.__.__. .__.__.__.__.__.,.__.__. .__.__.__.__.__.,.__.__.


.__.__.__.,.__.__. .__.__.__.__.__.,.__.__. .__.__.__.__.__.,.__.__.
.__.__.__.,.__.__. .__.__.__.__.__.,.__.__. .__.__.__.__.__.,.__.__.
.__.__.__.,.__.__. .__.__.__.__.__.,.__.__. .__.__.__.__.__.,.__.__.

63-Data e Assinatura de Procedimentos em Srie

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$
.__.__.__.__.__.__. , .__.__. .__.__.__.__.__.__. , .__.__.
.__.__.__.__.__.__.__.__. , .__.__.

86-Data e Assinatura do Solicitante

87-Data e Assinatura do Responsvel pela Autorizao 88-Data e Assinatura do Beneficirio ou Responsvel

.__.__. / .__.__. / .__.__.

1 3 / .__.__.
0 9 / .__.__.
1 1 CAMILA
.__.__.

.__.__. / .__.__. / .__.__.

89-Data e Assinatura do Prestador Executante

.__.__. / .__.__. / .__.__.