5
6.2) Guia de SP/SADT:
'
5-Senha
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
21 - Caráter do
Atendimento
|___|
23 - Indicação Clínica
68 - Assinatura do Contratado
66 - Assinatura do Responsável pela Autorização
59 - Total de Procedimentos (R$)
|___|___|___|___|___|___|___|___|,|___|___|
60 - Total de Taxas e Aluguéis (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
61 - Total de Materiais (R$)
|___|
___|___|___|___|___|___|___|,|___|___|
63 - Total de Medicamentos (R$)
|___|__
_|___|___|___|___|___|___|,|___|___|
3
-
Número da Guia Principal
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
64 - Total de Gases Medicinais (R$)
|___|___|__
_|___|___|___|___|___|,|___|___|
65 - Total Geral (R$)
|___|___|___|__
_|___|___|___|___|,|___|___|
GUIA DE SERVIÇO PROFISSIONAL / SERVIÇO AUXILIAR DE
DIAGNÓSTICO E TERAPIA - SP/SADT
1 - Registro ANS
|___|___|___|___|___|___|
10 - Nome
9 - Validade da Carteira
|___|___| / |___|___| / |___|___|___|___|
Dados do Beneficiário
13 - Código na Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
16 - Conselho
Profissional
|___|___|
17 - Número no Conselho
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
18
-
UF
|___|___|
14 - Nome do Contratado
Dados do Solicitante
15 - Nome do Profissional Solicitante
67 - Assinatura do Beneficiário ou Responsável
29 - Código na Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Dados do Contratado Executante
30 - Nome do Contratado
Dados da Solicitação / Procedimentos ou Itens Assistenciais Solicitados
6 - Data de Validade da Senha
|___|___| / |___|___| / |___|___|___|___|
Dados do Atendimento
Dados da Execução / Procedimentos e Exames Realizados
8 - Número da Carteira
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
56-Data de Realização de Procedimentos em Série 57-Assinatura do Beneficiário ou Responsável
1
- |___|___|/|___|___|/|___|___|___|___| __________________
3
- |___|___|/|___|___|/|___|___|___|___| __________________
5
- |___|___|/|___|___|/|___|___|___|___| _______________
7
- |___|___|/|___|___|/|___|___|___|___| _______________
9
- |___|___|/|___|___|/|___|___|___|___| _________________
2
- |___|___|/|___|___|/|___|___|___|___| __________________
4
- |___|___|/|___|___|/|___|___|___|___| __________________ 6 - |___|___|/|___|___|/|___|___|___|___| _______________
8
- |___|___|/|___|___|/|___|___|___|___| _______________ 10 - |___|___|/|___|___|/|___|___|___|___| ________________
24-Tabela 25- Código do Procedimento 26 - Descrição
27-Qtde. Solic. 28-Qtde.
Aut.
ou Item Assistencial
1
- |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___|
|___|___|___|
2
- |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___|
|___|___|___|
3
- |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___|
|___|___|___|
4
- |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___|
|___|___|___|
5
- |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___|
|___|___|___|
58-Observação / Justificativa
Logo da Empresa
11 - Cartão Nacional de Saúde
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
4 - Data da Autorização
|___|___| / |___|___| / |___|___|___|___|
33 - Indicação de Acidente (acidente ou doença relacionada)
|___|
32-Tipo de Atendimento
|___|___|
34 - Tipo de Consulta
|___|
36-Data 37-Hora Inicial 38-Hora Final 39-Tabela 40-Código do Procedimento 41-Descrição 42 - Qtde. 43-Via 44-Tec. 45- Fator Red./Acresc. 46-Valor Unitário (R$) 47-Valor Total (R$)
1
-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___|
|__|__|__|__|__|__|__|__|__|__|
_______________________________________________________________ |___|___|___| |___| |___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
2
-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___|
|__|__|__|__|__|__|__|__|__|__|
_______________________________________________________________ |___|___|___| |___| |___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
3
-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___|
|__|__|__|__|__|__|__|__|__|__|
_______________________________________________________________ |___|___|___| |___| |___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
4
-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___|
|__|__|__|__|__|__|__|__|__|__|
_______________________________________________________________ |___|___|___| |___| |___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
5
-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___|
|__|__|__|__|__|__|__|__|__|__|
_______________________________________________________________ |___|___|___| |___| |___|
|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
22 - Data da Solicitação
|___|___| / |___|___| / |___|___|___|___|
19 - Código CBO
|___
|___|___|___|___
|___|
31 - Código CNES
|___|___|___|___|___|___|___|
20 - Assinatura do Profissional Solicitante
48-Seq.Ref 49-Grau Part. 50-Código na Operadora/CPF 51-Nome do Profissional
52-Conselho 53-Número no Conselho 54-UF 55-Código CBO
Profissional
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ______________________________ __________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ______________________________ __________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ______________________________ __________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ______________________________ __________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
12 -Atendimento a RN
|___|
Identificação do(s) Profissional(is) Executante(s)
62- Total de OPME (R$)
|___|
___|___|___|___|___|___|___|,|___|___|
2- Nº Guia no Prestador
12345678901234567890
7 - Número da Guia Atribuído pela Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
35 - Motivo de Encerramento do Atendimento
|___|___|
