16
Dados do Beneficiário
GUIA DE SOLICITAÇÃO
DE PRORROGAÇÃO DE INTERNAÇÃO
OU COMPLEMENTAÇÃO DO TRATAMENTO
18 - Indicação Clínica
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Procedimentos ou Itens Assistenciais Adicionais Solicitados
25 - Tipo da Acomodação Autorizada
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27- Observação / Justificativa
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8 - Nome
Dados do Contratado Solicitante
9 - Código na Operadora
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10 - Nome do Contratado
11 - Nome do Profissional Solicitante
Dados da Internação
16 - Qtde. Diárias Adicionais Solicitadas
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Dados da Autorização
24 - Qtde. Diárias Adicionais Autorizadas
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7 - Número da Carteira
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Logo da Operadora
19-Tabela 20 - Código do Procedimento 21 - Descrição
22 - Qtde Solic 23
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Qtde Aut
ou Item Assistencial
1-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
2-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
3-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
4-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
5-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
6-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
7-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
8-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
9-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________________________________________________ |___|___|___| |___|___|___|
3
-
Número da Guia de Solicitação de Internação
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1 - Registro ANS
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17
-
Tipo da Acomodação Solicitada
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26 - Justificativa da operadora
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30 - Assinatura do Responsável pela Autorização
4 - Data da Autorização
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28 - Data da Solicitação
|___|___| / |___|___| / |___|___|___|___|
12 - Conselho
Profissional
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13 - Número no Conselho
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14
-
UF
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29 - Assinatura do Profissional Solicitante
2- Nº Guia no Prestador
12345678901234567890
5-Senha
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6 - Número da Guia Atribuído pela Operadora
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15 - Código CBO
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