8
ANEXO DE SOLICITAÇÃO DE QUIMIOTERAPIA
3 - Número da Guia Referenciada
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1 - Registro ANS
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44 - Data da Solicitação
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Dados do Beneficiário
Dados do Profissional Solicitante
8 - Nome
24 - Finalidade
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Medicamentos e Drogas solicitadas
4 - Senha
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5 - Data da Autorização
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7 - Número da Carteira
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45-Assinatura do Profissional Solicitante
Logo da Empresa
29-Data Prevista para Administração 30-Tabela 31-Código do Medicamento 32-Descrição
33-Doses 34-Via Adm 35-Frequência
1-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___|
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2-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
3-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
4-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
5-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
6-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
7-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
8-|___|___|/|___|___|/|___|___|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ________________________________________ |___|___|___|,|___|___| |___|___| |___|___|
15 - Telefone
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26 - PlanoTerapêutico
18 - CID 10 Principal
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41- Número de Ciclos
Previstos
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43-Intervalo entre
Ciclos ( em dias)
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42 - Ciclo Atual
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19 - CID 10 (2)
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21 - CID 10 (4)
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20 - CID 10 (3)
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9 - Peso (Kg)
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10 - Altura (Cm)
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11 - Superfície Corporal (m²)
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16 - E-mail
14 - Nome do Profissional Solicitante
Diagnóstico Oncológico
22
-
Estadiamento
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27 - Diagnóstico Cito/Histopatológico
12 - Idade
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13 - Sexo
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23 - Tipo de Quimioterapia
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28
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Informações relevantes
17 - Data do diagnóstico
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2- Nº Guia no Prestador
12345678901234567890
Tratamentos Anteriores
36- Cirurgia
37 - Data da Realização
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38 - Área Irradiada
39 - Data da Aplicação
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6 - Número da Guia Atribuído pela Operadora
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46-Assinatura do Responsável pela Autorização
40-Observação / Justificativa
25 - ECOG
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