21
6.9.1- Campos de Preenchimento Obrigatório
1,2,3,6,7,8,9,10,11,12,13,14,15,16,17,20,21,22,23,26,27,28,30,31,32,33,34,35, 36, 37, 38 e 39.
20- Tabela 87
25- Tabela 48
33- Tabela 26
36- Tabela 24
24- Tabela 61
30- Tabela 35 35- Tabela 59
6.9.2- Campos de Preenchimento Condicional
4- Deve ser preenchido em caso de autorização pela operadora com emissão de senha;
5- Deve ser preenchido caso a operadora atribua outro número à guia, independentemente do núme-
ro que a identifica no prestador;
18 e 19- Deve ser preenchido quando o procedimento ocorrer em situações de urgência e emergência.
24 e 25- Deve ser preenchido quando se tratar de procedimento cirúrgico.
29- Deve ser preenchido com o número da linha a que se refere a participação do profissional inte-
grante da equipe.
6.9.3- Campos de Preenchimento Opcional: 37
6.10 - Anexo de Outras Despesas
USO: Esta guia estará sempre vinculada a uma guia principal (Guia de SP/SADT ou Guia de Resumo
CNES
Dados do Contratado Executante
Despesas Realizadas
27 - Total Geral (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
26 - Total de Diárias (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
6-CD 7-Data 8-Hora Inicial 9-HoraFinal 10-Tabela 11-Códigodo Item 12-Qtde. 13-Unidade 14-FatorRed.. 15-ValorUnitário -R$ 16-ValorTotal
-
R$
17
-Registro ANVISA do Material
18
-Referência do material no fabricante
deMedida /Acresc 19
-Nº Autorização de Funcionamento
01-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
02-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
03-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
04-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
05-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
06-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
07-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
08-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
09-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
10-|___|___| |___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| |___|___|___|,|___|___|___|___| |___|___|___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |______________________________________________________________________________________________________________| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
20-Descrição _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
21 - Total de Gases Medicinais (R$
)
|___|___|__
_|___|___|___|___|___|,|___|___|
22 - Total de Medicamentos (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
23 - Total de Materiais (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
25 - Total de Taxas e Aluguéis (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
24 - Total de OPME (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
3 - Código na Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
4 - Nome do Contratado
5
-
Código CNES
|___|___|__
_|___|___|___|___|
ANEXO DE OUTRAS DESPESAS
(para Guia de SP/SADT e Resumo de Internação)
2
-
Número da Guia Referenciada
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
1 - Registro ANS
|___|___|___|___|___|___|
Logo da Empresa
de Internação), não existindo por si só. É utilizada na cobrança das despesas com materiais, medi-
camentos, aluguéis, diárias, OPME, gases e taxas diversas decorrentes dos atendimentos realizados
nas guias de SP/SADT e na guia Resumo de Internação. As instruções para preenchimento da guia de
internação encontram-se nas páginas 394 a 397 do Componente de Conteúdo e Estrutura, disponível
no Espaço dos Prestadores no endereço
/
