14
e
Dados do Beneficiário
GUIA DE SOLICITAÇÃO
DE INTERNAÇÃO
22 - Caráter do Atendimento
|___|
28 - Indicação Clínica
29-CID 10 Principal
|___|___|___|___|
30 - CID 10 (2)
|___|___|___|___|
32 - CID 10 (4 )
|___|___|___|___|
31 - CID 10 (3)
|___|___|___|___|
Procedimentos ou Itens Assistenciais Solicitados
41 - Tipo da Acomodação Autorizada
|___|___|
39 - Data Provável da Admissão Hospitalar
|___|___| / |___|___| / |___|___|___|___|
23-Tipo de Internação
|___|
45
-
Observação / Justificativa
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
4 - Data da Autorização
|___|___| / |___|___| / |___|___|___|___|
1 - Registro ANS
|___|___|___|___|___|___|
10 - Nome
8 - Validade da Carteira
|___|___| / |___|___| / |___|___|___|___|
11 - Cartão Nacional de Saúde
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Dados do Contratado Solicitante
12
-
Código na Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
15 - Conselho
Profissional
|___|___|
16 - Número no Conselho
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
17 - UF
|___|___|
18 - Código CBO
|___|___|___|___|___|___|
13 - Nome do Contratado
14 - Nome do Profissional Solicitante
Dados do Hospital /Local Solicitado / Dados da Internação
19- Código na Operadora / CNPJ
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20 - Nome do Hospital/Local Solicitado
25 - Qtde. Diárias Solicitadas
|___|___|___|
24 - Regime de Internação
|___|
Dados da Autorização
5 - Senha
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
6
-
Data de Validade da Senha
|___|___| / |___|___| / |___|___|___|___|
40 - Qtde. Diarias Autorizadas
|___|___|___|
42 - Código na Operadora / CNPJ autorizado
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
43 - Nome do Hospital / Local Autorizado
44 - Código CNES
|___|___|___|___|___|___|___|
7 - Número da Carteira
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Logo da Empresa
34-Tabela 35 - Código do Procedimento ou 36 - Descrição
37 - Qtde Solic 38
-
Qtde Aut
Item Assistencial
01-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ __ |___|___|___| |___|___|___|
02-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
03-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
04-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
05-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
06-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
07-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
08-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
09-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
10-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
11-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
12-
|___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________ ___ |___|___|___| |___|___|___|
21 - Data sugerida para internação
|___|___| / |___|___| / |___|___|___|___|
33 - Indicação de Acidente (acidente ou doença relacionada)
|___|
2- Nº Guia no Prestador
12345678901234567890
26
-
Previsão de uso de OPME
|___|
27
-
Previsão de uso de quimioterápico
|___|
9-Atendimento a RN
|___|
3 - Número da Guia Atribuído pela Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
46-Data da Solicitação
|___|___| / |___|___| / |___|___|___|___|
47-Assinatura do Profissional Solicitante
48-Assinatura do Beneficiário ou Responsável
49-Assinatura do Responsável pela Autorização
