Apostila TISS - page 12

12
4 - Data da Autorização
Versão 3
ANEXO DE SOLICITAÇÃO DE ÓRTESES, PRÓTESES E
MATERIAIS ESPECIAIS - OPME
Dados da Cirurgia
23 -Qtde.Nasc. Mortos
|___|___|
24 -Qtde. Nasc. VivosPrematuro
|___|___|
3 - Número da Guia Referenciada|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
5 - Data da Autorização
|___|___| / |___|___| / |___|___|___|___|
Dados do BeneficiárioDados do Profissional Solicitante9- Nome do Profissional Solicitante
8 - Nome
OPME Solicitadas 26 - Data da Solicitação
|___|___| / |___|___| / |___|___|___|___|
7 - Número da Carteira|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| 25- Observação / Justificativa
Logo da Empresa
12
-Justificativa Técnica
10 - Telefone(|___|___|) |___|___|___|___|___|-|___|___|___|___|
11 - E-mail
24 - Especificação do Material 13-Tabela 14-Código do Material 15-Descrição
16-Opção 17- Qtde. Solicitada 18- Valor Unitário Solicitado 19- Qtde. Autorizada 20- Valor Unitário Autorizado
21-Registro ANVISA do Material 22-Referência do material no fabricante
23-Nº Autorização de Funcionamento
01- |___|___| |___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________________________| |___|
|___|___|___|
|___|___|___|___|___|___|,|___|___
| |___|___|___|
|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |_________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
02- |___|___| |___|___|___|___|___|___|___|___|___|___| |_______________________________________________________________________________________________________________________________| |___| |___|___|___|
|___|___|___|___|___|___|,|___|___
| |___|___|___|
|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |_________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
03- |___|___| |___|___|___|___|___|___|___|___|___|___| |_____________________________________________________________________________________________________________________________| |___| |___|___|___|
|___|___|___|___|___|___|,|___|___
| |___|___|___|
|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |_________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
04- |___|___| |___|___|___|___|___|___|___|___|___|___| |_____________________________________________________________________________________________________________________________| |___| |___|___|___|
|___|___|___|___|___|___|,|___|___
| |___|___|___|
|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |_________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
05- |___|___| |___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________________________| |___| |___|___|___|
|___|___|___|___|___|___|,|___|___
| |___|___|___|
|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |_____________________________________________________ ____________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
06- |___|___| |___|___|___|___|___|___|___|___|___|___| |_____________________________________________________________________________________________________________________________ |___| |___|___|___|
|___|___|___|___|___|___|,|___|___
| |___|___|___|
|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |_________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
1 - Registro ANS|___|___|___|___|___|___|
4 - Senha|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
2- Nº Guia no Prestador
12345678901234567890
27- Assinatura do Profissional Solicitante
6 - Número da Guia Atribuído pela Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
28- Assinatura do Responsável pela Autorização