2- N Guia no Prestador

GUIA DE SERVIO PROFISSIONAL / SERVIO AUXILIAR DE

DIAGNSTICO E TERAPIA - SP/SADT
1 - Registro ANS 3 Nmero da Guia Principal

31.292-4 |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
4 - Data da Autorizao 5-Senha 6 - Data de Validade da Senha 7 - Nmero da Guia Atribudo pela Operadora

|___|___| / |___|___| / |___|___|___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| / |___|___| / |___|___|___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Dados do Benecirio
8 - Nmero da Carteira 9 - Validade da Carteira 10 - Nome 11 - Carto Nacional de Sade 12 -Atendimento a RN

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| / |___|___| / |___|___|___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|

Dados do Solicitante
13 - Cdigo na Operadora 14 - Nome do Contratado

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

15 - Nome do Prossional Solicitante 16 - Conselho 17 - Nmero no Conselho 18 UF 19 - Cdigo CBO 20 - Assinatura do Prossional Solicitante
Prossional
|___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

Dados da Solicitao / Procedimentos ou Itens Assistenciais Solicitados

21 - Carter do 22 - Data da Solicitao 23 - Indicao Clnica
Atendimento
|___| |___|___| / |___|___| / |___|___|___|___|

24-Tabela 25- Cdigo do Procedimento 26 - Descrio 27-Qtde. Solic. 28-Qtde. Aut.

ou Item Assistencial
1 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___| |___|___|___|

2 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___| |___|___|___|

3 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___| |___|___|___|

4 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___| |___|___|___|

5 - |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________________________________________________________________________________________________________________________ |___|___|___| |___|___|___|

Dados do Contratado Executante

29 - Cdigo na Operadora 30 - Nome do Contratado 31 - Cdigo CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___|___|___|___|___|___|

Dados do Atendimento
32-Tipo de Atendimento 33 - Indicao de Acidente (acidente ou doena relacionada) 34 - Tipo de Consulta 35 - Motivo de Encerramento do Atendimento

|___|___| |___| |___| |___|___|

Dados da Execuo / Procedimentos e Exames Realizados

36-Data 37-Hora Inicial 38-Hora Final 39-Tabela 40-Cdigo do Procedimento 41-Descrio 42 - Qtde. 43-Via 44-Tec. 45- Fator Red./Acresc. 46-Valor Unitrio (R$) 47-Valor Total (R$)

1-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___| |__|__|__|__|__|__|__|__|__|__| _______________________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|

2-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___| |__|__|__|__|__|__|__|__|__|__| _______________________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|

3-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___| |__|__|__|__|__|__|__|__|__|__| _______________________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|

4-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___| |__|__|__|__|__|__|__|__|__|__| _______________________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|

5-|___|___|/|___|___|/|___|___|___|___| |__|__|:|__|__| a |__|__|:|__|__| |___|___| |__|__|__|__|__|__|__|__|__|__| _______________________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|

Identicao do(s) Prossional(is) Executante(s)

48-Seq.Ref 49-Grau Part. 50-Cdigo na Operadora/CPF 51-Nome do Prossional 52-Conselho 53-Nmero no Conselho 54-UF 55-Cdigo CBO
Prossional
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________ ______________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________ ______________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________ ______________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________ ______________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___|___|___|___|___|___|

56-Data de Realizao de Procedimentos em Srie 57-Assinatura do Benecirio ou Responsvel

1- |___|___|/|___|___|/|___|___|___|___| __________________ 3 - |___|___|/|___|___|/|___|___|___|___| __________________ 5 - |___|___|/|___|___|/|___|___|___|___| _______________ 7 - |___|___|/|___|___|/|___|___|___|___| _______________ 9 - |___|___|/|___|___|/|___|___|___|___| _________________

2- |___|___|/|___|___|/|___|___|___|___| __________________ 4 - |___|___|/|___|___|/|___|___|___|___| __________________ 6 - |___|___|/|___|___|/|___|___|___|___| _______________ 8 - |___|___|/|___|___|/|___|___|___|___| _______________ 10 - |___|___|/|___|___|/|___|___|___|___| ________________
58-Observao / Justicativa

59 - Total de Procedimentos (R$) 60 - Total de Taxas e Aluguis (R$) 61 - Total de Materiais (R$) 62- Total de OPME (R$) 63 - Total de Medicamentos (R$) 64 - Total de Gases Medicinais (R$) 65 - Total Geral (R$)

|___|___|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|___|___|,|___|___|

66 - Assinatura do Responsvel pela Autorizao 67 - Assinatura do Benecirio ou Responsvel 68 - Assinatura do Contratado

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