10
ANEXO DE SOLICITAÇÃO DE RADIOTERAPIA
14 - Data do diagnóstico
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3 - Número da Guia Referenciada
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1 - Registro ANS
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40 - Data da Solicitação
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Dados do Beneficiário
Dados do Profissional Solicitante
8 - Nome
20 - Estadiamento
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4 -Senha
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5 - Data da Autorização
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7 - Número da Carteira
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41-Assinatura do Profissional Solicitante
Logo da Empresa
12 - Telefone
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15 - CID 10 Principal
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34 - Número de Campos
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35 - Dose por dia (em Gy)
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16 - CID 10 (2)
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18 - CID 10 (4)
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17 - CID 10 (3)
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13 - E-mail
11 - Nome do Profissional Solicitante
Diagnóstico Oncológico
23 - Diagnóstico Cito/Histopatológico
19 - Diagnóstico por Imagem
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36 - Dose Total ( em Gy)
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37 - Número de Dias
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38 - Data Prevista para Início da Administração
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Procedimentos Complementares
29-Data Prevista 30-Tabela 31-Código do Procedimento 32-Descrição
33-Qtde.
01-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
02-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
03-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
04-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
05-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
06-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
29-Data Prevista 30-Tabela 31-Código do Procedimento 32-Descrição
33-Qtde.
07-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
08-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
09-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
10-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
11-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
12-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________ |___|___|___|,|___|___|
24 - Informações relevantes
22 - Finalidade
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10 - Sexo
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9 - Idade
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Tratamentos Anteriores
25 - Cirurgia
26 - Data da Realização
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27 - Quimioterapia
28 - Data da Aplicação
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21 - ECOG
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2- Nº Guia no Prestador
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6 - Número da Guia Atribuído pela Operadora
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42-Assinatura do Autorizador da Operadora
39-Observação/Justificativa
